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BACKGROUND Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E) carriage is frequent among liver transplant (LT) recipients, thereby fostering a large empirical carbapenem prescription. However, ESBL-E infections occur in only 10%-25% of critically ill patients with rectal colonization. Our aim was to identify risk factors for post-LT ESBL-E infection in colonized patients. The effect of perioperative antimicrobial prophylaxis (AP) was also analyzed in patients with prophylaxis lasting

International audience; BACKGROUND : In this prospective study, we describe the electroencephalographic (EEG) profiles in children anesthetized with sevoflurane or propofol.METHODS : Seventy-three subjects (11 years, range 5-18) were included and randomly assigned to two groups according to the anesthetic agent. Anesthesia was performed by target-controlled infusion of propofol (group P) or by sevoflurane inhalation (group S). Steady-state periods were performed at a fixed randomized concentration between 2, 3, 4, 5, and 6 μg.ml-1 of propofol in group P and between 1, 2, 3, 4, and 5% of sevoflurane in group S. Remifentanil was continuously administered throughout the study. Clinical data, Bispectral Index (BIS), and raw EEG were continuously recorded. The relationship between BIS and anesthetic concentrations was studied using nonlinear regression. For all steady-state periods, EEG traces were reviewed to assess the presence of epileptoid signs, and spectral analysis of raw EEG was performed.RESULTS : Under propofol, BIS decreased monotonically and EEG slowed down as concentrations increased from 2 to 6 μg.ml-1 . Under sevoflurane, BIS decreased from 0% to 4% and paradoxically rose from 4% to 5% of expired concentration: this increase in BIS was associated with the occurrence of fast oscillations and epileptoid signs on the EEG trace. Propofol was associated with more delta waves and burst suppression periods compared to sevoflurane.CONCLUSION : Under deep anesthesia, the BIS and electroencephalographic profiles differ between propofol and sevoflurane. For high concentrations of sevoflurane, an elevated BIS value may be interpreted as a sign of epileptoid patterns or EEG fast oscillations rather than an insufficient depth of hypnosis.

International audience; Donor-derived fungal infections can be associated with severe complications in transplant recipients. Donor-derived candidiasis has been described in kidney transplant recipients where contamination of the preservation fluid (PF) was a commonly proposed source. In liver transplantation, these fungal infections have been less explored. The aim of this study was therefore to determine the incidence and clinical relevance of Candida contamination of preservation fluid in the context of liver transplantation. A 5-year (2008-2012) retrospective multicentre study involving six French liver transplantation centers was performed to determine the incidence of Candida PF contamination. Postoperative clinical features, outcomes in recipients, and risk factors for Candida-related complications of liver transplantation were studied. Candida sp. was isolated from 28 of 2107 preservation fluid samples (1.33%). Candida albicans was the most common yeast (n = 18, 64%). Twenty-two recipients (78.5%) received antifungal therapy (echinocandins in 68%) for 7-37 days. Eight patients developed yeast-related complications (28.6%) including hepatic artery aneurysms (n = 6) and Candida peritonitis (n = 2). The 1-year mortality rate among patients after a yeast-related complication was 62.5%. The incidence of Candida PF contamination was low, but was associated with dramatic postoperative complications and high mortality. Close radiological follow-up may enable early recognition of the arterial complications associated with PF contamination by Candida.

Although laparoscopic pancreatic resection (LPR) has become routine, large single-center series are still lacking. Our aim was to analyze the results of a large European single-center series of LPR.Between January 2008 and September 2015, 300 LPRs were performed and studied prospectively, including 165 (55%) distal pancreatectomies, 68 (23%) pancreaticoduodenectomies (PDs), 30 (10%) enucleations, 35 (11%) central pancreatectomies, and 2 (1%) total pancreatectomies.Mean age was 54 ± 15.4 years old (range 17 to 87 years), and most patients were women (58%). Laparoscopic pancreatic resection was performed for malignancy (46%), low potential malignant (44%), or benign (10%) diseases. The mean operative durations were 211 ± 102 minutes (range 30 to 540 minutes) for the entire population and 351 ± 59 minutes (range 240 to 540 minutes) for PD, and decreased with the learning curve. Mean blood loss was 229 ± 269 mL (range 0 to 1,500 mL), and 13 patients (4%) received transfusions. Conversion to an open procedure was required in 12 patients (4%), and only 5 in the last 250 patients (14% vs 2%; p0.001). Mortality occurred in 4 (1.3%) patients and only after PD (5.8%). Common complications were pancreatic fistula (n = 124, 41%), bleeding (n = 35, 12%), and reoperation (n = 28, 9%). The postoperative outcomes were less favorable in procedures with a reconstruction phase (n = 105) than in those without (n = 195), with increased mortality (3.8% vs 0%; p = 0.04), overall morbidity (76% vs % 52%; p 0.001), and mean hospital stay (26 ± 15 days vs 16 ± 10 days; p0.001).Laparoscopic pancreatic resection without a reconstruction phase has excellent outcomes; LPR with a reconstruction phase, especially PD, has less favorable outcomes, and further randomized studies are required to draw conclusions on the safety and benefits of this approach.

Older liver grafts have been considered in the past decade due to organ shortage. The aim was to compare outcomes after liver transplantation with either younger or older donors.Patients transplanted in our center between 2004 and 2014 with younger donors (younger than 60 years; n = 253) were compared with older donors (older than 75 years; n = 157). Multiorgan transplantations, split grafts, or non-heart-beating donors were not included.Donors in the older group were mostly women deceased from stroke, and only 3 patients had experienced cardiac arrest. Liver tests were significantly better in the older group than in the younger group. There was no difference regarding cold ischemia time, model for end-stage liver disease score, and steatosis. There was no significant difference regarding primary nonfunction and dysfunction, hepatic artery and biliary complications, and retransplantation rates. Graft survival was not different (65% and 64% in the older and younger groups, P = 0.692). Within the older group, hepatitis C infection, retransplantation, and emergency transplantation were associated with poor graft survival.Provided normal liver tests and the absence of cardiac arrest in donors, older liver grafts (75 years) may be safely attributed to non-hepatitis C-infected recipients in the setting of a first and nonurgent transplantation.

High-flow nasal cannula (HFNC) oxygen therapy is attracting increasing interest in acute medicine as an alternative to standard oxygen therapy; however, its use to prevent hypoxaemia after major abdominal surgery has not been evaluated. Our trial was designed to close this evidence gap. A multicentre randomised controlled trial was carried out at three university hospitals in France. Adult patients at moderate to high risk of postoperative pulmonary complications who had undergone major abdominal surgery using lung-protective ventilation were randomly assigned using a computer-generated sequence to receive either HFNC oxygen therapy or standard oxygen therapy (low-flow oxygen delivered via nasal prongs or facemask) directly after extubation. The primary endpoint was absolute risk reduction (ARR) for hypoxaemia at 1 h after extubation and after treatment discontinuation. Secondary outcomes included occurrence of postoperative pulmonary complications within 7 days after surgery, the duration of hospital stay, and in-hospital mortality. The analysis was performed on data from the modified intention-to-treat population. This trial was registered with ClinicalTrials.gov (NCT01887015). Between 6 November 2013 and 1 March 2015, 220 patients were randomly assigned to receive either HFNC (n = 108) or standard oxygen therapy (n = 112); all of these patients completed follow-up. The median duration of the allocated treatment was 16 h (interquartile range 14–18 h) with standard oxygen therapy and 15 h (interquartile range 12–18) with HFNC therapy. Twenty-three (21 %) of the 108 patients treated with HFNC 1 h after extubation and 29 (27 %) of the 108 patients after treatment discontinuation had postextubation hypoxaemia, compared with 27 (24 %) and 34 (30 %) of the 112 patients treated with standard oxygen (ARR 4, 95 % CI –8 to 15 %; p = 0.57; adjusted relative risk [RR] 0.87, 95 % CI 0.53–1.43; p = 0.58). Over the 7-day postoperative follow-up period, there was no statistically significant difference between the groups in the proportion of patients who remained free of any pulmonary complication (ARR 7, 95 % CI –6 to 20 %; p = 0.40). Other secondary outcomes also did not differ significantly between the two groups. Among patients undergoing major abdominal surgery, early preventive application of high-flow nasal cannula oxygen therapy after extubation did not result in improved pulmonary outcomes compared with standard oxygen therapy.

Brain natriuretic peptide (BNP) serum concentration has been shown to be a preoperative predictor of postoperative outcome in high risk surgery. Whether it is able to predict early post-liver transplantation (LT) mortality in cirrhotic patients is unanswered.Prospective monocenter observational study including all consecutive patients who received LT for cirrhosis and for whom a preoperative BNP serum dosage was available between January 2011 and December 2014.During the period, 207 cirrhotic patients among 525 LT were studied. The ICU and 180-day mortality rates were, respectively, 6% and 8%. Pre-LT BNP concentration, adjusted on model of end-stage liver disease (MELD) score, was an independent factor of ICU and 180-day mortality rates (for each 50 pg/mL increase; hazard ratio, 1035 [1.022-1.049]; P0.001 and 1.035 [1.014-1057]; P = 0.001). According to the receiver operator characteristic curve with an accuracy of 0.79 (0.66-0.93), the optimal cutoff value of pre-LT BNP serum level to predict ICU mortality was 155 pg/mL with a negative predictive value of 99%. All patients with MELD score exceeding 25 and pre-LT serum BNP level less than 155 pg/mL survived, whereas patients combining MELD score exceeding 25 and pre-LT BNP concentration exceeding 155 pg/mL had a 27% ICU mortality rate (P = 0.03).In cirrhotic patients, pre-LT BNP serum level was an independent predictor of post-LT ICU mortality. With its excellent negative predictive value, the use of this biomarker in combination with MELD score could be useful to better predict post-LT early outcome.

Introduction L’infection a Clostridium difficile (ICD) est une infection frequente en reanimation associee a une surmorbidite et une surmortalite. L’immunodepression est susceptible d’en aggraver les consequences. Peu de donnees sont disponibles concernant l’ICD en transplantation hepatique (TH). Le but de cette etude est d’identifier l’incidence des ICD en reanimation apres TH, d’evaluer les differents facteurs favorisants et d’estimer la morbidite et la mortalite liees a l’ICD. Materiel et methodes Etude epidemiologique retrospective a partir d’une base de donnees prospective, incluant tous les patients transplantes hepatiques, entre mars 2010 et decembre 2014 durant leur sejour postoperatoire en reanimation. Le traitement immunosuppresseur etait compose de prednisone, tacrolimus, micoplenolate mofetil chez tous les patients. Le diagnostic d’ICD reposait sur une symptomatologie diarrheique associee a la detection de la bacterie par immuno-enzymologie et detection de toxines par PCR en temps reel (B, binaire, O27). Les donnees continues sont presentees sous forme de mediane et quartiles, les donnees dichotomisees en termes de pourcentage, les donnees entre patient ICD+/ICD–sont compares par des tests non parametriques et regression logistique. Resultats Au total, 504 patients ont ete transplantes entre mars 2010 et decembre 2014 et 34 (6,7 %) ont developpe une ICD [94 % (n = 32) avec toxine B, 6 % (n = 2) une toxine binaire]. Le delai entre TH et diagnostic d’ICD etait de 9 jours [5–16]. 9 % des patients (n = 3) avaient un antecedent d’ICD avant la TH. Quinze pour cent (n = 5) etaient traites par antibiotiques au moment du diagnostic. Parmi les ICD + 23 patients (79 %) avaient recu des antibiotiques pendant plus de 24 h dans une periode de 90 jours precedant l’ICD. Le traitement de premiere intention etait une monotherapie par metronidazole per os chez 32 patients (94 %) et bitherapie metronidazole et vancomycine per os chez 2 patients, pour une duree de 14 jours. Premiere recidive traitee par metronidazole (n = 3) ou vancomycine (n = 2). Deuxieme recidive traitee par metronidazole (n = 1). Quatorze pour cent (n = 5) des patients ont eu une recidive, dans un delai median de 59 jours, 1 a developpe une deuxieme recidive, 4 patients avaient toujours une pression en antibiotique au moment de la recidive. L’evolution a ete favorable sans chirurgie ( Tableau 1 ). Discussion L’incidence francaise de l’ICD en reanimation polyvalente est de 1,3 % [1] . L’instauration d’une immunodepression et une pression importante en antibiotiques expliquent probablement la forte incidence d’ICD chez les patients transplantes hepatiques. Le sepsis semble etre un facteur de risque plus important d’ICD en reanimation que la gravite de l’atteinte hepatique.

Objective: To study the correlation between fungal colonization and bacterial pneumonia and to test the effect of antifungal treatments on the development of bacterial pneumonia in colonized rats. Design: Experimental animal investigation. Setting: University research laboratory. Subjects: Pathogen-free male Wistar rats weighing 250–275 g. Interventions: Rats were colonized by intratracheal instillation of Candida albicans. Fungal clearance from the lungs and immune response were measured. Both colonized and noncolonized animals were secondarily instilled with different bacterial species (Pseudomonas aeruginosa, Escherichia coli, or Staphylococcus aureus). Bacterial phagocytosis by alveolar macrophages was evaluated in the presence of interferon-gamma, the main cytokine produced during fungal colonization. The effect of antifungal treatments on fungal colonization and its immune response were assessed. The prevalence of P. aeruginosa pneumonia was compared in antifungal treated and control colonized rats. Measurements and Main Results: C. albicans was slowly cleared and induced a Th1-Th17 immune response with very high interferon-gamma concentrations. Airway fungal colonization favored the development of bacterial pneumonia. Interferon-gamma was able to inhibit the phagocytosis of unopsonized bacteria by alveolar macrophages. Antifungal treatment decreased airway fungal colonization, lung interferon-gamma levels and, consequently, the prevalence of subsequent bacterial pneumonia. Conclusions: C. albicans airway colonization elicited a Th1-Th17 immune response that favored the development of bacterial pneumonia via the inhibition of bacterial phagocytosis by alveolar macrophages. Antifungal treatment decreased the risk of bacterial pneumonia in colonized rats.

Introduction L’encephalopathie hepatique (EH) est une pathologie frequente en cas de maladie hepatique, aussi bien en cas d’insuffisance hepatique aigue (IHA) qu’en cas de cirrhose. En cas d’IHA, elle est associee a des perturbations de l’hemodynamique intracerebrale et de l’autoregulation cerebrale pouvant aboutir a une hypertension intracrânienne [1] . Dans ces circonstances, les modalites de surveillance neurologique sont tres peu etudiees. L’indice de pulsatilite (IP) mesure par Doppler transcrânien (DTC) pourrait permettre une meilleure surveillance dans cette population specifique. L’objectif de ce travail etait de decrire l’evolution de l’IP avant et au decours de la TH chez des patients souffrant d’EH dans un contexte d’IHA ou de cirrhose. Materiel et methodes Apres accord du comite d’ethique, des mesures d’IP au niveau de l’artere cerebrale moyenne par DTC ont ete realisees en pre- et en post-TH chez des patients cirrhotiques sans antecedent d’EH, avec antecedent d’EH aigue ou chronique et en cas d’IHA. Ces mesures etaient realisees quotidiennement jusqu’a reveil et extubation post-TH. Le stade d’EH pre-TH ou le pire stade d’EH deja decrit, selon la classification de West Haven, ont ete colliges. Les donnees demographiques, biologiques et postoperatoires ont egalement ete recueillies. Le j0 post-TH est defini dans notre service comme le jour de sortie du bloc operatoire. Les resultats sont presentes en mediane [IQR] ou pourcentage. Resultats De janvier 2013 a decembre 2014, des mesures d’IP ont ete realisees chez 41 patients : 5 patients cirrhotiques sans EH (groupe temoin), 22 cirrhotiques avec antecedent d’EH aigue ou chronique et 14 IHA. En absence d’EH, les valeurs d’IP pre- et post-TH a j0 etaient normales, respectivement 1,01 [0,84–1,03] et 1,07 [1,06–1,08]. Chez les cirrhotiques avec EH, l’IP post-TH etait legerement augmentee par rapport a l’IP pre-TH, respectivement 1,25 [1,01–1,44] et 1,05 [1–1,26]. Cette valeur se normalise ensuite des j1. En cas d’IHA, des resultats similaires sont retrouves (IP pre-TH 1,12 [1,03–1,27], IP j0 1,38 [0,96–1,52]). En cas d’IHA et d’EH severe (grade 3 et 4), les valeurs d’IP pre-TH etaient significativement superieures a celles des patients avec EH legere (grade 1 et 2) ( Fig. 1 , respectivement 1,48 [1,22–1,66] vs 1,04 [0,99–1,12], p = 0,01). Ce resultat etait retrouve a j0 mais sans atteindre le seuil de significativite (1,55 [1,49–1,67] vs 0,84 [0,75–1,08]). Discussion En cas d’IHA avec EH, la surveillance de l’IP de l’artere cerebrale moyenne par DTC en pre- et en post-TH permet de detecter des alterations de l’hemodynamique cerebrale qui se normalisent 24 a 36 heures apres la TH. La surveillance du DTC pourrait permettre, de surveiller et adapter les therapeutiques de neuroreanimation en cas d’IHA compliquee d’EH severe.