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Les critères du diagnostic de la mort ont évolué au cours de l’histoire de l’Homme. Cette évolution est allée de pair avec des changements de valeurs sociétales. Pendant longtemps, la mort survenait sur les lieux de vie du patient entouré de ses proches et des représentants religieux. Mourir à l’hôpital était un signe d’indigence et de solitude. L’arrêt de la respiration et de la circulation étaient les critères d’affirmation du décès. Pour autant, ce diagnostic était parfois incertain. La mort s’est progressivement médicalisée. L’essor des techniques de réanimation a fondamentalement bousculé les frontières de la mort, aboutissant à la notion de mort encéphalique. Cette évolution fait distinguer la mort de la personne et la mort biologique. On meurt de plus en plus à l’hôpital ou en institution, loin de tout ce qui était notre vie. Cette mort en milieu hospitalier renforce la sensation d’une toute puissance médicale sur le moment et les conditions de celle-ci. Le médecin doit déclarer non plus une réalité irréfutable, mais l’irréversibilité d’un processus qui peut être remis en cause par les techniques de réanimation. L’élargissement pour des raisons utilitaristes des critères de prélèvements d’organes à des patients en impasse thérapeutique, peut faire craindre la notion de mort sociale ouvrant la voie à l’euthanasie et au suicide assisté.

International audience; Purpose: To investigate the impact of Macintosh blade size used during direct laryngoscopy (DL) on first-attempt intubation success of orotracheal intubation in French intensive care units (ICUs). We hypothesized that success rate would be higher with Macintosh blade size No3 than with No4.Methods: Multicenter retrospective observational study based on data from prospective trials conducted in 48 French ICUs of university, and general and private hospitals. After each intubation using Macintosh DL, patients’ and operators’ characteristics, Macintosh blade size, results of first DL and alternative techniques used, as well as the need of a second operator were collected. Complications rates associated with intubation were investigated. Primary outcome was success rate of first DL using Macintosh blade.Results: A total of 2139 intubations were collected, 629 with a Macintosh blade No3 and 1510 with a No4. Incidence of first-pass intubation after first DL was significantly higher with Macintosh blade No3 (79.5 vs 73.3%, p = 0.0025), despite equivalent Cormack–Lehane scores (p = 0.48). Complications rates were equivalent between groups. Multivariate analysis concluded to a significant impact of Macintosh blade size on first DL success in favor of blade No3 (OR 1.44 [95% CI 1.14–1.84]; p = 0.0025) without any significant center effect on the primary outcome (p = 0.18). Propensity scores and adjustment analyses concluded to equivalent results.Conclusion: In the present study, Macintosh blade No3 was associated with improved first-passed DL in French ICUs. However, study design requires the conduct of a nationwide prospective multicenter randomized trial in different settings to confirm these results.

Resume L’extubation des patients cerebroleses est marquee par une absence de recommandations fortes. La prediction du succes de l’extubation des patients cerebroleses reste incertaine a ce jour. Le prerequis universel a toute extubation en reanimation est l’existence d’un etat de conscience suffisant, ou en tout cas compatible avec cet acte, c’est-a-dire un score de Glasgow > 12. Ce n’est bien souvent pas possible chez certains patients cerebroleses, et leur extubation doit reposer sur d’autres criteres, notamment si l’etat de conscience reste altere. Une evaluation fine de la gestion du carrefour aero-pharynge (reflexe nauseeux, toux, secretions, deglutition…) et de l’etat de conscience (scores CRS-R, suivi du regard…) du patient peut aider a la prediction du succes de l’extubation.

Context Low doses of ketamine are commonly used to decrease opiates tolerance, hyperalgesia and delirium in perioperative theatre but these properties have never been studied in intensive care unit (ICU) patients. Purpose To determine the impact of ketamine infusion on opiates consumption when added to standard care in ICU patients requiring sedation for mechanical ventilation. Methods Patients admitted in a general ICU of a university hospital and undergoing mechanical ventilation (n = 162) with nurse-driven sedation protocol were randomly assigned into ketamine (2 mg/kg/h) or placebo in a double-blinded control trial. Patients were assessed for sedation and analgesia levels, opiates consumption and delirium (using the Confusion Assessment Method for ICU). Results Daily consumption of remifentanil (7.9 ± 1.0 vs. 9.3 ± 1.0 μg/kg/h, P = 0.548) and increase in remifentanil doses required for equianalgesia (0.107 ± 0.17 and 0.11 ± 0.18 μg/kg/min, P = 0.78) were not different between ketamine and control groups. The incidence was higher in the placebo group 30/82 (37%) than in the ketamine group 17/80 (21%) (P = 0.03). The duration of delirium was lower in ketamine group (5.3 ± 4.7 vs. 2.8 ± 3 days, P = 0.005). Mortality rates, ventilator-free days and ICU length of stay (LOS) were non-statistically different in both groups. Conclusions When the best practices of sedation (nurse-driven sedation, a consistent light-to-moderate sedation level, and delirium monitoring) are used for all patients, the addition of low doses of ketamine does not decrease opiate consumption but reduces delirium incidence and its duration in medico-surgical ICU patients with no effect on mortality rate and ICU LOS.

International audience; Since 1988, France has been committed to drafting laws regulating clinical research. These laws must both reflect general legal standards relating to personal data protection and patient information and comply with EU regulations, which are supra-national norms. The 2012 legislation known as "Jardé law" came into force in 2016 and distinguishes between 3 different types of research involving human subjects: category 1:interventional research implying an intervention on the patient which is not justified by their usual treatment. Category 2: interventional research, which does not focus on medicinal products and only entails minimal risks and constraints. Category 3: non-interventional research implying one or multiple acts or proceedings devoid of listed risks. These studies require preliminary favourable opinions from the French Ethical Research Committees (CPP), who are appointed by the State, and must ensure the protection of personal data. For the other types of studies (retrospective data, practice surveys), French legislation only requires that the protection of personal data is ensured. However, it is highly recommended to submit these studies to an Institutional Review Board (IRB) in order to confirm that human subjects are not involved and to obtain an ethical opinion in the event of a scientific journal submission. These laws are constantly evolving in order to comply with the various international recommendations and European regulations, which are binding in France.

The plasma soluble receptor for advanced glycation end-products (sRAGE) is a marker of lung epithelial injury with prognostic value when measured at baseline in acute respiratory distress syndrome (ARDS). However, whether changes in plasma sRAGE could inform prognosis in ARDS remains unknown. In this secondary analysis of the Lung Imaging for Ventilator Setting in ARDS (LIVE) multicenter randomized controlled trial, which evaluated a personalized ventilation strategy tailored to lung morphology, plasma sRAGE was measured upon study entry (baseline) and on days one, two, three, four and six. The association between changes in plasma sRAGE over time and 90-day survival was evaluated. Higher baseline plasma sRAGE (HR per-one log increment, 1.53, 95% CI, 1.16–2.03, p = 0.003) and an increase in sRAGE over time (HR for each one-log increment in plasma sRAGE per time unit, 1.01, 95% CI, 1.01–1.02, p &lt, 10−3) were both associated with increased 90-day mortality. Each 100-unit increase in the plasma sRAGE level per unit of time increased the risk of death at day 90 by 1% in joint modeling. Plasma sRAGE increased over time when a strategy of maximal alveolar recruitment was applied in patients with focal ARDS. Current findings suggest that the rate of change in plasma sRAGE over time is associated with 90-day survival and could be helpful as a surrogate outcome in ARDS.

Background Current intensive care unit (ICU) sedation guidelines recommend strategies using non-benzodiazepine sedatives. This survey was undertaken to explore inhaled ICU sedation practice in France. Methods In this national survey, medical directors of French adult ICUs were contacted by phone or email between July and August 2019. ICU medical directors were questioned about the characteristics of their department, their knowledge on inhaled sedation, and practical aspects of inhaled sedation use in their department. Results Among the 374 ICUs contacted, 187 provided responses (50%). Most ICU directors (73%) knew about the use of inhaled ICU sedation and 21% used inhaled sedation in their unit, mostly with the Anaesthetic Conserving Device (AnaConDa, Sedana Medical). Most respondents had used volatile agents for sedation for Conclusion This survey highlights the widespread knowledge about inhaled ICU sedation in France but shows its limited use to date. Differences in education and knowledge, as well as the recent and relatively scarce literature on the use of volatile agents in the ICU, might explain the diverse practices that were observed. The low rate of mild adverse effects, as perceived by respondents, and the users’ satisfaction, are promising for this potentially important tool for ICU sedation.

Preclinical studies have shown that volatile anesthetics may have beneficial effects on injured lungs, and pilot clinical data support improved arterial oxygenation, attenuated inflammation, and decreased lung epithelial injury in patients with acute respiratory distress syndrome (ARDS) receiving inhaled sevoflurane compared to intravenous midazolam. Whether sevoflurane is effective in improving clinical outcomes among patients with ARDS is unknown, and the benefits and risks of inhaled sedation in ARDS require further evaluation. Here, we describe the SESAR (Sevoflurane for Sedation in ARDS) trial designed to address this question. SESAR is a two-arm, investigator-initiated, multicenter, prospective, randomized, stratified, parallel-group clinical trial with blinded outcome assessment designed to test the efficacy of sedation with sevoflurane compared to intravenous propofol in patients with moderate to severe ARDS. The primary outcome is the number of days alive and off the ventilator at 28 days, considering death as a competing event, and the key secondary outcome is 90 day survival. The planned enrollment is 700 adult participants at 37 French academic and non-academic centers. Safety and long-term outcomes will be evaluated, and biomarker measurements will help better understand mechanisms of action. The trial is funded by the French Ministry of Health, the European Society of Anaesthesiology, and Sedana Medical.

International audience; Acute respiratory distress syndrome (ARDS) is a common cause of hypoxemic respiratory failure and death in critically ill patients, and there is an urgent need to find effective therapies. Preclinical studies have shown that inhaled halogenated agents may have beneficial effects in animal models of ARDS. The development of new devices to administer halogenated agents using modern intensive care unit (ICU) ventilators has significantly simplified the dispensing of halogenated agents to ICU patients. Because previous experimental and clinical research suggested potential benefits of halogenated volatiles, such as sevoflurane or isoflurane, for lung alveolar epithelial injury and inflammation, two pathophysiologic landmarks of diffuse alveolar damage during ARDS, we designed an animal model to understand the mechanisms of the effects of halogenated agents on lung injury and repair. After general anesthesia, tracheal intubation, and the initiation of mechanical ventilation, ARDS was induced in piglets via the intratracheal instillation of hydrochloric acid. Then, the piglets were sedated with inhaled sevoflurane or isoflurane using an ICU-type device, and the animals were ventilated with lung-protective mechanical ventilation during a 4 h period. During the study period, blood and alveolar samples were collected to evaluate arterial oxygenation, the permeability of the alveolar-capillary membrane, alveolar fluid clearance, and lung inflammation. Mechanical ventilation parameters were also collected throughout the experiment. Although this model induced a marked decrease in arterial oxygenation with altered alveolar-capillary permeability, it is reproducible and is characterized by a rapid onset, good stability over time, and no fatal complications. We have developed a piglet model of acid aspiration that reproduces most of the physiological, biological, and pathological features of clinical ARDS, and it will be helpful to further our understanding of the potential lung-protective effects of halogenated agents delivered through devices used for inhaled ICU sedation.

Volatile anaesthetic agents, especially sevoflurane, could be an alternative for sedating ICU patients. In the operating theatre, volatile anaesthetic agents are monitored using minimal alveolar concentration (MAC). In ICU, MAC may be used to assess sedation level and may replace clinical scale especially when they are unusable. Therefore, we sought to investigate the minimal sevoflurane end-tidal concentration to achieved deep sedation in critical ill patients: MAC-deep sedation (MAC-DS).In a prospective interventional study, we included patients with a Richmond Assessment Sedation Score (RASS) of 0 without any sedation. We stepwise increased sevoflurane concentration level before assessing for deep sedation (RASS≤-3). MAC-DS was defined as the minimal sevoflurane MAC fraction or sevoflurane expiratory fraction (FeSevo) to get 90% and 95% of patients in deep sedation (MAC-DS 90 and MAC-DS 95, respectively).Between June and November 2014, 30 patients were included (median age=60 years [interquartile range: 47-69]). Increasing sevoflurane MAC was correlated with a decrease in RASS values (r=-0.83, P0.001). MAC-DS 90 and MAC-DS 95 were achieved at 0.42 MAC (CI 95 [0.38-0.46]) and 0.46 MAC (CI 95 [0.42-0.51]), respectively. FeSevo to achieve MAC-DS 90 and MAC-DS 95 was 0.72 (CI 95 [0.65-0.79]) and 0.80 (CI 95 [0.72-0.89]), respectively.In this physiological study involving 30 ICU patients, MAC-DS, end-tidal sevoflurane concentration to get 95% of patients in deep sedation determined over more than 500 observations, is achieved at 0.8% of expired fraction of sevoflurane or at 0.5 age-adjusted MAC.

Background The Radiographic Assessment of Lung Edema (RALE) score is associated with the severity of ARDS, and treatments targeted at reducing pulmonary edema such as conservative fluid management cause a reduction in RALE score over time. Research Question Are early changes in RALE score over time associated with survival in patients with ARDS? Study Design and Methods Data from patients enrolled in three centers in the Lung Imaging for Ventilation sEtting in ARDS (LIVE) trial with available chest radiographs at baseline (day 0) and days 2 or 3 were used. The RALE was scored by two independent reviewers. The primary end point was death by day 90, considering RALE score both at baseline and as a time-varying covariate in a marginal Cox survival model. Results RALE was scored from 135, 64, and 88 radiographs on days 0, 2, and 3, respectively. Both baseline RALE (hazard ratio [HR] for each one-point increment, 1.04; 95% CI, 1.01-1.08; P = .006) and the change in RALE over time (HR for each one-point decrease per unit of time, 0.99; 95% CI, 0.99-0.99; P = .03) were associated with death by day 90, even after adjustment for age, sex, BMI, Simplified Acute Physiology Score II, vasopressor use, and total volume of fluids received since study entry. Interpretation The change in RALE during the first days after ARDS onset is independently associated with survival and may be useful as a surrogate end point in future clinical trials of new therapeutics in ARDS.

Resume Depuis novembre 2016, une nouvelle loi encadrant les recherches impliquant la personne humaine, dite loi Jarde, est applicable, remplacant la loi qui reglementait la recherche biomedicale interventionnelle depuis 1988. La particularite essentielle de la loi Jarde est de concerner toutes les recherches impliquant la personne humaine (RIPH) et impose la soumission de tous les projets a un Comite de protection des personnes (CPP) tire au sort. La loi definit trois categories de recherches selon le niveau de risque encouru par la personne qui s’y prete : les RIPH interventionnelles, les RIPH qui ne comportent qu’un risque minime (precise par arrete) et les RIPH non interventionnelles. Dans chacune de ces trois categories, le niveau de contraintes reglementaires et les conditions de recueil du consentement sont differents et modules en fonction du risque. Les recherches portant sur les pratiques professionnelles ou d’enseignement, ainsi que les recherches en sciences humaines et sociales, et les recherches sur donnees retrospectives ne sont pas considerees comme des RIPH. Des avis ethiques peuvent etre demandes aupres des comites d’ethique, pour ces etudes afin de satisfaire aux obligations des comites editoriaux des revues internationales.

Resume Certains reglages du respirateur comme la fraction inspiree en oxygene, le debit d’insufflation, le reglage d’une pause tele-inspiratoire, le rapport entre le temps inspiratoire et le temps expiratoire, ainsi que d’autres reglages specifiques aux modes ventilatoires assistes ont moins fait l’objet d’etudes cliniques que le reglage du volume courant ou de la pression tele-expiratoire positive par exemple. Pourtant, ces reglages, dits « caches », peuvent avoir un impact majeur sur l’efficacite de la ventilation ainsi que sur le confort et le travail respiratoire du patient. L’interet principal de bien connaitre ses reglages est de toujours chercher, lorsque cela est possible, d’adapter le respirateur au patient et non d’adapter le patient au respirateur.

We sought to validate a French translation of the Iowa Satisfaction with Anesthesia Scale (ISAS), a tool to assess the patient's satisfaction with monitored anesthesia care for surgery. The ISAS tool is particularly pertinent as surgery with monitored anesthesia care is increasingly used in ambulatory surgery settings.We studied content validity, internal consistency, convergent validity (vs physician-estimated satisfaction), and test-retest reliability of the French version of the ISAS (ISAS-F) in 122 adult patients undergoing a brief outpatient invasive procedure under conscious sedation. The ISAS-F was answered twice by the patient, once in the postanesthesia care unit and once before discharge from the ambulatory care unit.The median [interquartile range (IQR)] time of completion at the first assessment was 2 [2-4] min. The total median [IQR] ISAS-F score was 2.3 [1.8-2.7]. Internal consistency of the ISAS-F was found to be good (Cronbach's α = 0.68). Test-retest reliability was significant, with an intra-class correlation coefficient at 0.74 (95% confidence interval [CI], 0.63 to 0.85). The ISAS-F score correlated with the physician-estimated satisfaction score, with an intra-class correlation coefficient of 0.28 (95% CI, 0.12 to 0.44; P = 0.01).This validated version of the ISAS can now be used by French-speaking researchers and physicians to assess patient satisfaction with the anesthesia technique.RéSUMé: OBJECTIF: Nous avons voulu valider une traduction française de l’échelle de satisfaction par rapport à l’anesthésie de l’Iowa (ISAS), un outil d’évaluation de la satisfaction du patient par rapport aux soins sous surveillance anesthésique lors de chirurgies. L’outil ISAS est particulièrement pertinent étant donné que les chirurgies réalisées sous surveillance anesthésique sont de plus en plus fréquemment utilisées dans le contexte de chirurgie ambulatoire. MéTHODE: Nous avons étudié la validité de contenu, la cohérence interne, la validité convergente (vs la satisfaction estimée par le médecin) et la fiabilité de test-retest de la version française de l’ISAS (ISAS-F) auprès de 122 patients adultes subissant une courte intervention ambulatoire sous sédation légère. Les patients ont répondu deux fois au ISAS-F, soit une fois en salle de réveil et une seconde fois avant de recevoir leur congé de l’unité de soins ambulatoires. RéSULTATS: Le temps médian [écart interquartile (ÉIQ)] pour compléter le test lors de la première évaluation était de 2 [2–4] min. Le score total médian [ÉIQ] sur l’ISAS-F était de 2,3 [1,8–2,7]. La cohérence interne de l’ISAS-F était bonne (α de Cronbach = 0,68). La fiabilité de test-retest était appréciable, avec un coefficient de corrélation intraclasse de 0,74 (intervalle de confiance [IC] 95 %, 0,63 à 0,85). Le score sur l’ISAS-F était corrélé au score de satisfaction tel qu’estimé par le médecin, avec un coefficient de corrélation intraclasse de 0,28 (IC 95 %, 0,12 à 0,44; P = 0,01). DISCUSSION: Cette version validée de l’ISAS peut désormais être utilisée par les chercheurs et médecins francophones afin d’évaluer la satisfaction des patients avec la technique anesthésique employée.

IntroductionDifficult airway management during tracheal intubation can lead to severe hypoxic sequelae. Routine intubation practice is to use a strict supine position, whereas a 25° head-up or reverse Trendelenburg position increases efficacy of preoxygenation, seems more comfortable for the anaesthetist and may also provide better intubation conditions in direct laryngoscopy. The 25° head-up position could be used for the whole population rather than only for obese patients, but there is no prospective randomised controlled trial with a robust design and large number of patients comparing strict supine against 25° intubation in operating room. The objective of the InSize25 study is to test the effect of these two patient positions on intubation conditions during laryngoscopy in scheduled surgery on non-obese patients.Methods and analysisInSize25 is an investigator-initiated, multicentre, open-label, two-arm, randomised controlled trial. The InSize25 study will randomise 1000 adult patients scheduled for surgery under general anaesthesia requiring intubation with neuromuscular-blocking drugs, candidates for direct laryngoscopy. The primary outcome variable is the view obtained during the first laryngoscopy without any external manipulation assessed using percentage of glottic opening. Important secondary outcomes are: Cormack-Lehane classification, number of attempts at laryngoscopy and at tracheal intubation, use of ancillary equipment (eg, bougies, alternative laryngoscope blades, videolaryngoscope) and manoeuvres (eg, laryngeal manipulation), comfort score for the anaesthetist, episodes of postinduction hypotension or desaturation and mechanical complications of intubation.Ethics and disseminationThe trial received appropriate approval from the ‘CPP Sud-Est II’ ethical review board. Informed consent is required. If the 25° head-up position proves superior for tracheal intubation without more complications, it may become the routine-standard intubation position rather than only for use with obese patients. The final results will be published in a peer-reviewed journal.Trial registration numberClinicaltrials.gov identifier (NCT03339141).

IntroductionEndovascular thrombectomy is the standard of care for anterior circulation acute ischaemic stroke (AIS) secondary to emergent large vessel occlusion in patients who qualify. General anaesthesia (GA) or conscious sedation (CS) is usually required to ensure patient comfort and avoid agitation and movement during thrombectomy. However, the question of whether the use of GA or CS might influence functional outcome remains debated. Indeed, conflicting results exist between observational studies with better outcomes associated with CS and small monocentric randomised controlled trials favouring GA. Therefore, we aim to evaluate the effect of CS versus GA on functional outcome and periprocedural complications in endovascular mechanical thrombectomy for anterior circulation AIS.Methods and analysisAnesthesia Management in Endovascular Therapy for Ischemic Stroke (AMETIS) trial is an investigator initiated, multicentre, prospective, randomised controlled, two-arm trial. AMETIS trial will randomise 270 patients with anterior circulation AIS in a 1:1 ratio, stratified by centre, National Institutes of Health Stroke Scale (≤15 or >15) and association of intravenous thrombolysis or not to receive either CS or GA. The primary outcome is a composite of functional independence at 3 months and absence of perioperative complication occurring by day 7 after endovascular therapy for anterior circulation AIS. Functional independence is defined as a modified Rankin Scale score of 0–2 by day 90. Perioperative complications are defined as intervention-associated arterial perforation or dissection, pneumonia or myocardial infarction or cardiogenic acute pulmonary oedema or malignant stroke evolution occurring by day 7.Ethics and disseminationThe AMETIS trial was approved by an independent ethics committee. Study began in august 2017. Results will be published in an international peer-reviewed medical journal.Trial registration numberNCT03229148.

The effect of personalised mechanical ventilation on clinical outcomes in patients with acute respiratory distress syndrome (ARDS) remains uncertain and needs to be evaluated. We aimed to test whether a mechanical ventilation strategy that was personalised to individual patients' lung morphology would improve the survival of patients with ARDS when compared with standard of care.We designed a multicentre, single-blind, stratified, parallel-group, randomised controlled trial enrolling patients with moderate-to-severe ARDS in 20 university or non-university intensive care units in France. Patients older than 18 years with early ARDS for less than 12 h were randomly assigned (1:1) to either the control group or the personalised group using a minimisation algorithm and stratified according to the study site, lung morphology, and duration of mechanical ventilation. Only the patients were masked to allocation. In the control group, patients received a tidal volume of 6 mL/kg per predicted bodyweight and positive end-expiratory pressure (PEEP) was selected according to a low PEEP and fraction of inspired oxygen table, and early prone position was encouraged. In the personalised group, the treatment approach was based on lung morphology; patients with focal ARDS received a tidal volume of 8 mL/kg, low PEEP, and prone position. Patients with non-focal ARDS received a tidal volume of 6 mL/kg, along with recruitment manoeuvres and high PEEP. The primary outcome was 90-day mortality as established by intention-to-treat analysis. This study is registered online with ClinicalTrials.gov, NCT02149589.From June 12, 2014, to Feb 2, 2017, 420 patients were randomly assigned to treatment. 11 patients were excluded in the personalised group and nine patients were excluded in the control group; 196 patients in the personalised group and 204 in the control group were included in the analysis. In a multivariate analysis, there was no difference in 90-day mortality between the group treated with personalised ventilation and the control group in the intention-to-treat analysis (hazard ratio [HR] 1·01; 95% CI 0·61-1·66; p=0·98). However, misclassification of patients as having focal or non-focal ARDS by the investigators was observed in 85 (21%) of 400 patients. We found a significant interaction between misclassification and randomised group allocation with respect to the primary outcome (p0·001). In the subgroup analysis, the 90-day mortality of the misclassified patients was higher in the personalised group (26 [65%] of 40 patients) than in the control group (18 [32%] of 57 patients; HR 2·8; 95% CI 1·5-5·1; p=0·012.Personalisation of mechanical ventilation did not decrease mortality in patients with ARDS, possibly because of the misclassification of 21% of patients. A ventilator strategy misaligned with lung morphology substantially increases mortality. Whether improvement in ARDS phenotyping can decrease mortality should be assessed in a future clinical trial.French Ministry of Health (Programme Hospitalier de Recherche Clinique InterRégional 2013).

International audience; BackgroundSevoflurane has anti-inflammatory proprieties and short lasting effects making it of interest for procedural sedation in critically ill patients. We evaluated the pharmacokinetics of sevoflurane and metabolites in severely ill burn patients and controls. The secondary objective was to assess potential kidney injury.MethodsProspective interventional study in a burn and a surgical intensive care unit; 24 mechanically ventilated critically ill patients (12 burns, 12 controls) were included. The sevoflurane was administered with an expired fraction target of 2% during short-term procedural sedation. Plasma concentrations of sevoflurane, hexafluoroisopropanolol (HFIP) and free fluoride ions were recorded at different times. Kinetic Pro (Wgroupe, France) was used for pharmacokinetic analysis. Kidney injury was assessed with neutrophil gelatinase-associated lipocalin (NGAL).ResultsThe mean total burn surface area was 36 ± 11%. The average plasma concentration of sevoflurane was 70.4 ± 37.5 mg·L−1 in burns and 57.2 ± 28.1 mg·L−1 in controls at the end of the procedure (P = 0.58). The volume of distribution was higher (46.8 ± 7.2 vs 22.2 ± 2.50 L, P < 0.001), and the drug half-life longer in burns (1.19 ± 0.28 h vs 0.65 ± 0.04 h, P < 0.0001). Free metabolite HFIP was higher in burns. Plasma fluoride was not different between burns and controls. NGAL did not rise after procedures.ConclusionWe observed an increased volume of distribution, slower elimination rate, and altered metabolism of sevoflurane in burn patients compared to controls. Repeated use for procedural sedation in burn patients needs further evaluation. No renal toxicity was detected.

Previous clinical trials for laparoscopic surgery have included few elderly patients aged ≥75 years. We aimed to evaluate the quality of postoperative recovery after laparoscopic surgery using low intraperitoneal pressure (IPP) (6 mm Hg) and warmed, humidified carbon dioxide gas for genital prolapse in elderly patients aged ≥75 years.Prospective consecutive case series.University hospital.Consecutive patients (n = 30) aged ≥75 years planning to undergo laparoscopic surgery for genital prolapse by the same surgeon were recruited from October 2016 through December 2019.Laparoscopic promontofixation for the treatment of genital prolapse was performed using low IPP and warmed, humidified carbon dioxide gas. When a promontory could not be easily identified, laparoscopic pectopexy was alternatively performed.The primary outcome was the Quality of Recovery-40 (QoR-40) score at 24 hours postoperatively. The secondary outcomes were postoperative pain using a 100-mm visual analog scale and the length of hospital stay after surgery (LHSS). For the global QoR-40 score and for 4 dimensions of the QoR-40, "emotional state," "physical comfort," "psychologic support," and "pain," no differences were observed between the baseline score and the score at 24 hours. The score for the "physical independence" dimension at 24 hours was significantly lower than the baseline score (p.001). No patient had visual analog scale pain scores30 out of 100 at 12 hours or later. LHSS was48 hours in 22 patients (73.3%) and72 hours in 8 patients (26.7%). Multivariable analysis showed that the odds of an LHSS48 hours were more than 8 times higher in patients who were discharged from the operating room in the afternoon compared with those with a morning discharge.The use of a low IPP is feasible, safe, and has clinical benefits for elderly patients aged ≥75 years who undergo laparoscopic surgery for genital prolapse.

Fetus in fetus (FIF) is an extremely rare congenital condition characterized by the parasitic development of a malformed fetal twin within a normal second twin’s body. The localization is mostly abdominal in the retroperitoneum. Thoracic localization is extremely rare. In this clinical case, a 5 month old female infant weighing 5 kg presented with a chest mass causing respiratory distress. We realized a chest CT-Scan; the latter revealed a heterogeneous mass, completely occupying the left hemithorax. Imaging studies confirmed the presence of the fetus in fetus occupying the entire left hemithorax and mediastinum, pushing the heart to the right. A complete resection of the mass could be performed under general anesthesia and orotracheal intubation (GA + OTI). The monitoring involved ECG, SpO2, NIBP, PR, T°, and Capnometry. The ventilation was first mechanical and secondarily manual. The patient did not receive unipulmonary ventilation nor central IV line. Postoperative period marked by volume overload, anemia, cardiac arrest, with successful resuscitation. Histopathology studies and imaging confirmed the diagnosis. On D9, she was discharged from pediatric critical care and from hospital on day ten postoperative. She presented in good clinical condition after a 3-month follow-up. We report this case in order to show how we took care of this FIF case in the precarious conditions.

Resume L’interet et les limites de la delegation des tâches anesthesiques sont exposes sous l’angle de la qualite des soins, de la responsabilite des aspects reglementaires et economiques et en comparant les organisations en place dans differents pays.

Resume Les complications respiratoires sont frequentes en anesthesie pediatrique, et parmi elles, le spectre du laryngospasme reste tres redoute. La prevention est fondamentale chez les enfants ayant des facteurs de risque. La symptomatologie associe une ventilation inefficace et une desaturation arterielle en oxygene. Cependant, le diagnostic est bien souvent porte par exces. L’echographie peut permettre d’observer la fermeture des cordes vocales et donc guider les therapeutiques a mettre en œuvre rapidement afin d’eviter des complications potentiellement letales. Nous proposons de discuter la physiopathologie, les facteurs de risque identifies, les mesures de prevention et de traitement du laryngospasme chez l’enfant. Nous discutons egalement l’interet de l’echographie dans le diagnostic du laryngospasme.

Importance It is not known if use of colloid solutions containing hydroxyethyl starch (HES) to correct for intravascular deficits in high-risk surgical patients is either effective or safe. Objective To evaluate the effect of HES 130/0.4 compared with 0.9% saline for intravascular volume expansion on mortality and postoperative complications after major abdominal surgery. Design, Setting, and Participants Multicenter, double-blind, parallel-group, randomized clinical trial of 775 adult patients at increased risk of postoperative kidney injury undergoing major abdominal surgery at 20 university hospitals in France from February 2016 to July 2018; final follow-up was in October 2018. Interventions Patients were randomized to receive fluid containing either 6% HES 130/0.4 diluted in 0.9% saline (n = 389) or 0.9% saline alone (n = 386) in 250-mL boluses using an individualized hemodynamic algorithm during surgery and for up to 24 hours on the first postoperative day, defined as ending at 7:59amthe following day. Main Outcomes and Measures The primary outcome was a composite of death or major postoperative complications at 14 days after surgery. Secondary outcomes included predefined postoperative complications within 14 days after surgery, durations of intensive care unit and hospital stays, and all-cause mortality at postoperative days 28 and 90. Results Among 826 patients enrolled (mean age, 68 [SD, 7] years; 91 women [12%]), 775 (94%) completed the trial. The primary outcome occurred in 139 of 389 patients (36%) in the HES group and 125 of 386 patients (32%) in the saline group (difference, 3.3% [95% CI, −3.3% to 10.0%]; relative risk, 1.10 [95% CI, 0.91-1.34];P = .33). Among 12 prespecified secondary outcomes reported, 11 showed no significant difference, but a statistically significant difference was found in median volume of study fluid administered on day 1: 1250 mL (interquartile range, 750-2000 mL) in the HES group and 1500 mL (interquartile range, 750-2150 mL) in the saline group (median difference, 250 mL [95% CI, 83-417 mL];P = .006). At 28 days after surgery, 4.1% and 2.3% of patients had died in the HES and saline groups, respectively (difference, 1.8% [95% CI, −0.7% to 4.3%]; relative risk, 1.76 [95% CI, 0.79-3.94];P = .17). Conclusions and Relevance Among patients at risk of postoperative kidney injury undergoing major abdominal surgery, use of HES for volume replacement therapy compared with 0.9% saline resulted in no significant difference in a composite outcome of death or major postoperative complications within 14 days after surgery. These findings do not support the use of HES for volume replacement therapy in such patients. Trial Registration ClinicalTrials.gov Identifier:NCT02502773

International audience; Acute respiratory distress syndrome (ARDS) is a syndrome of diffuse alveolar injury with impaired alveolar fluid clearance and severe inflammation. The use of halogenated agents, such as sevoflurane or isoflurane, for the sedation of intensive care unit (ICU) patients can improve gas exchange, reduce alveolar edema, and attenuate inflammation during ARDS. However, data on the use of inhaled agents for continuous sedation in the ICU to treat or prevent lung damage is lacking. To study the effects of halogenated agents on alveolar epithelial cells under "physiologic" conditions, we describe an easy system to culture cells at the air-liquid interface and expose them to halogenated agents to provide precise controlled "air" fractions and "medium" concentrations for these agents. We developed a sealed air-tight chamber in which plates with human alveolar epithelial immortalized cells could be exposed to a precise, controlled fraction of sevoflurane or isoflurane using a continuous gas flow provided by an anesthetic machine circuit. Cells were exposed to 4% of sevoflurane and 1% of isoflurane for 24 hours. Gas mass spectrometry was performed to determine the concentration of halogenated agents dissolved in the medium. After the first hour, the concentrations of sevoflurane and isoflurane in the medium were 251 mg/L and 25 mg/L, respectively. The curves representing the concentrations of both sevoflurane and isoflurane dissolved in the medium showed similar courses over time, with a plateau reached at one hour after exposure. This protocol was specifically designed to reach precise and controlled concentrations of sevoflurane or isoflurane in vitro to improve our understanding of mechanisms involved in epithelial lung injury during ARDS and to test novel therapies for the syndrome.

Acute respiratory distress syndrome (ARDS) is a syndrome of diffuse alveolar injury with impaired alveolar fluid clearance and severe inflammation. The use of halogenated agents, such as sevoflurane or isoflurane, for the sedation of intensive care unit (ICU) patients can improve gas exchange, reduce alveolar edema, and attenuate inflammation during ARDS. However, data on the use of inhaled agents for continuous sedation in the ICU to treat or prevent lung damage is lacking. To study the effects of halogenated agents on alveolar epithelial cells under "physiologic" conditions, we describe an easy system to culture cells at the air-liquid interface and expose them to halogenated agents to provide precise controlled "air" fractions and "medium" concentrations for these agents. We developed a sealed air-tight chamber in which plates with human alveolar epithelial immortalized cells could be exposed to a precise, controlled fraction of sevoflurane or isoflurane using a continuous gas flow provided by an anesthetic machine circuit. Cells were exposed to 4% of sevoflurane and 1% of isoflurane for 24 hours. Gas mass spectrometry was performed to determine the concentration of halogenated agents dissolved in the medium. After the first hour, the concentrations of sevoflurane and isoflurane in the medium were 251 mg/L and 25 mg/L, respectively. The curves representing the concentrations of both sevoflurane and isoflurane dissolved in the medium showed similar courses over time, with a plateau reached at one hour after exposure. This protocol was specifically designed to reach precise and controlled concentrations of sevoflurane or isoflurane in vitro to improve our understanding of mechanisms involved in epithelial lung injury during ARDS and to test novel therapies for the syndrome.

Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2 × 2 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8 mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12 mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CD gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12 hours and 0.06 (95% CI: 0.01, 0.26) at 24 hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0 hours and 0.29 (95% CI: 0.10, 0.79) at 12 hours in the WH gas group versus the CD gas group.

International audience

Different acute respiratory distress syndrome (ARDS) phenotypes may explain controversial results in clinical trials. Lung-morphology is one of the ARDS-phenotypes and physiological studies suggest different responses in terms of positive-end-expiratory-pressure (PEEP) and recruitment-manoeuvres (RM) according to loss of aeration. To evaluate whether tailored ventilator regimens may impact ARDS outcomes, our group has designed a randomised-clinical-trial of ventilator settings according to lung morphology in moderate-to-severe ARDS (LIVE study). Method Patients will be enrolled within the first 12 hours of ARDS onset. In both groups, volume-controlled ventilation with low tidal-volumes (Vt) will be used to target a plateau pressure ≤ 30 cmH 2 O. In the control group, the PEEP level and inspired fraction of oxygen (FiO 2 ) will be set using the ARDSNet table; a Vt of 6 mL/kg of predicted body weight (PBW) will be set and prone position (PP) will be applied. In the intervention arm, the ventilator will be set according to lung morphology (focal/non-focal) that will be assessed according to CT-scan ± chest x-ray + lung echography. For focal ARDS patients, a Vt of 8 mL/kg PBW will be used along with low PEEP and PP. For non-focal ARDS patients, a Vt of 6 mL/kg PBW will be used with RM and PEEP to reach a plateau pressure ≤ 30 cmH 2 O. The primary outcome is all-cause 90-day mortality and the secondary outcomes are: in-hospital mortality, mortality at day 28, 60, 180 and 365; ventilator-free days at day 30, quality of life at one year; ventilator-associated pneumonia rate; barotrauma; ICU and hospital length of stay. This RCT is registered on Clinicaltrials.gov under identifier NCT02149589 .

The rationale for the use of recruitment maneuvers (RMs) in acute respiratory distress syndrome (ARDS) is to promote alveolar recruitment, leading to an increased end-expiratory lung volume and thus decreased ventilator-induced lung injury (VILI). RMs consists of a transient increase in transpulmonary pressure that can re-open previously collapsed alveoli. RMs represents a physiological response to lung aggression in different conditions by re-opening the collapsed part of the lung and decreasing lung oedema. This process can be accomplished through a variety of methods. The RM that has probably been used most commonly is sustained inflation, but recruitment can be achieved by a prolonged sigh, leading to a lesser increase in transpulmonary pressure for a longer period of time. This extended sigh seems to be more efficient, with less haemodynamic compromise. Knowledge of physiological determinants is crucial to selecting good levels of pressure and time required to perform an efficient and well-tolerated RM. Identifying ARDS patients who may benefit from RMs is a major issue, depending essentially on the amount of recruitable lung involved. In any case, however, RMs should be done at the early phase of ARDS.

The creation of a pneumoperitoneum for laparoscopic surgery is performed by the insufflation of carbon dioxide (CO2). The insufflated CO2 is generally at room temperature (20–25 °C) and dry (0–5 % relative humidity). However, these physical characteristics could lead to alterations of the peritoneal cavity, leading to operative and postoperative complications. Warming and humidifying the insufflated gas has been proposed to reduce the iatrogenic effects of laparoscopic surgery, such as pain, hypothermia and peritoneal alterations. Two medical devices are currently available for laparoscopic surgery with warm and humidified CO2. Clinical studies were identified by searching PubMed with keywords relating to humidified and warmed CO2 for laparoscopic procedures. Analysis of the literature focused on postoperative pain, analgesic consumption, duration of hospital stay and convalescence, surgical techniques and hypothermia. Bibliographic analyses reported 114 publications from 1977 to 2015, with only 17 publications of clinical interest. The main disciplines focused on were gynaecological and digestive surgery ). Analysis of the studies selected reported only a small beneficial effect of warmed and humidified laparoscopy compared to standard laparoscopy on immediate postoperative pain and per procedure hypothermia. No difference was observed for later postoperative shoulder pain, morphine equivalent daily doses, postoperative body core temperature, recovery room and hospital length of stay, lens fogging and procedure duration. Only few beneficial effects on immediate postoperative pain and core temperature have been identified in this meta-analysis. Although more studies are probably needed to close the debate on the real impact of warmed and humidified CO2 for laparoscopic procedures.

Background:Sevoflurane sedation in the intensive care unit is possible with a special heat and moisture exchanger called the Anesthetic Conserving Device (ACD) (AnaConDa®; Sedana Medical AB, Uppsala, Sweden). The ACD, however, may corrupt ventilatory mechanics when used during the weaning process of intensive care unit patients. The authors compared the ventilatory effects of light-sedation with sevoflurane administered with the ACD and those of classic management, consisting of a heated humidifier and intravenous sedation, in intensive care unit patients receiving pressure-support ventilation.Methods:Fifteen intensive care unit patients without chronic pulmonary disease were included. A target Richmond Agitation Sedation Scale level of −1/−2 was obtained with intravenous remifentanil (baseline 1-condition). Two successive interventions were tested: replacement of the heated humidifier by the ACD without sedation change (ACD-condition) and sevoflurane with the ACD with an identical target level (ACD-sevoflurane-condition). Patients finally returned to baseline (baseline 2-condition). Work of breathing, ventilatory patterns, blood gases, and tolerance were recorded. A steady state of 30 min was achieved for each experimental condition.Results:ACD alone worsened ventilatory parameters, with significant increases in work of breathing (from 1.7 ± 1.1 to 2.3 ± 1.2 J/l), minute ventilation, P0,1, intrinsic positive end-expiratory pressure (from 1.3 ± 2.6 to 4.7 ± 4.2 cm H2O), inspiratory pressure swings, and decreased patient comfort. Sevoflurane normalized work of breathing (from 2.3 ± 1.2 to 1.8 ± 1 J/l), intrinsic positive end-expiratory pressure (from 4.7 ± 4.2 to 1.8 ± 2 cm H2O), inspiratory pressure swings, other ventilatory parameters, and patient tolerance.Conclusions:ACD increases work of breathing and worsens ventilatory parameters. Sevoflurane use via the ACD (for a light-sedation target) normalizes respiratory parameters. In this patient’s population, light-sedation with sevoflurane and the ACD may be possible during the weaning process.

Resume L’application d’une pression cricoidienne ou manœuvre de Sellick, est, associee a une sequence rapide d’induction–intubation, une prophylaxie de l’inhalation du contenu chez les patients a risque eleve de regurgitation. Elle fait l’objet de recommandations d’experts et de societes savantes, alors qu’aucun essai clinique randomise n’atteste de son efficacite, validee uniquement par des etudes observationnelles et sur cadavre. La manœuvre de Sellick est principalement accusee de deformer le larynx, de degrader le score de Cormack et Lehane et d’augmenter les difficultes d’intubation. Ces objections sont liees a une meconnaissance de la manœuvre qui est trop souvent mal realisee : la pression appliquee est soit trop forte genant l’intubation ou trop faible et alors inefficace. La pression est aussi frequemment, appliquee sur le cartilage thyroide, entrainant alors effectivement une distorsion des structures anatomiques. Une pression cricoidienne de 10 N chez le patient conscient, renforcee a 30 N des la perte de connaissance, ne deforme que peu l’anatomie du larynx et n’augmente ni la difficulte ni la duree d’intubation. Son application reste donc recommandee lors de la prise en charge de patients a risque d’inhalation, en respectant les contre-indications. Un enseignement plus rigoureux, s’appuyant sur de nouveaux outils de simulations et un monitorage des pressions imposees devraient eteindre les controverses.

Resume Le terme de « ventilation non invasive » (VNI) regroupe l’ensemble des techniques d’assistance ventilatoire visant a maintenir une ventilation alveolaire en prenant en charge tout ou partie du travail respiratoire en l’absence de dispositif intratracheal. L’utilisation de la VNI a pour objectif de compenser tout ou partie des atteintes de la fonction ventilatoire liees a la chirurgie en diminuant le travail des muscles respiratoires, en ameliorant la ventilation alveolaire, les echanges gazeux et en diminuant les atelectasies. Lors de la periode postoperatoire apres une chirurgie lourde, l’application precoce d’une ventilation non invasive a visee prophylactique peut permettre de reduire le risque de complications respiratoires. L’utilisation de la VNI pour le traitement curatif de patients presentant une insuffisance respiratoire aigue postoperatoire doit etre prudente, respecter les contre-indications et eliminer une complication chirurgicale. La place de la VNI dans le traitement des insuffisances respiratoires aigues postoperatoires est encore mal etablie, en raison principalement du manque de puissance des etudes randomisees controlees actuellement disponibles.