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Implantations for uterovaginal brachytherapy are usually performed under general or spinal anesthesia, which are not without risk. As it is a rather short procedure and since postoperative pain is minimal, hypnosedation was proposed to selected patients requiring endocavitary applications as part of their routine treatment.Consecutive patients requiring intracavitary uterovaginal brachytherapy from January to October 2019 were included if they accepted the procedure. A premedication was systematically administered. Hypnosedation was based on an Ericksonian technique. The procedure was immediately interrupted if the patient requested it, in cases of extreme anxiety or pain. Procedure was in that case rescheduled with a "classical" anesthesia technique.A total of 20 patients were included. Four patients had to be converted toward a general anesthesia: one because of a fibroma on the probe's way and three young patients with a very anteverted/retroverted uterus that was painful at every mobilization. Mean and maximum pain scores during implant were 2.9/10 and 5.1/10, respectively. The most painful maneuver was cervical dilation for 45% of the patients, followed by mold insertion in 40% of cases. About 85% of the patients declared that hypnosis helped them relax; 90% of the patients would recommend the technique. No procedure-related complication occurred.With a 70% success rate (correct implant with mean pain and anxiety scores 5), one can conclude that uterovaginal brachytherapy implantation under hypnosedation is feasible and received a high satisfaction rate from the patients. This technique may reduce overall treatment time in a context of difficult access to the OR and to anesthesiologists, while reducing anesthetic drugs resort and postoperative nausea.

Resume Le vieillissement de la population est associee a une augmentation d’actes chirurgicaux et donc du nombre d’anesthesie generales et locoregionales. A ce titre, la fracture du col femoral concerne plus de 75 000 patients par an et constitue donc un enjeu de sante publique du fait d’une morbi-mortalite non negligeable. Les experts issus de quatre societes savantes, la SFAR, la SOFCOT, la SFGG et la SFPC ont redige 26 recommandations concernant la prise en charge perioperatoire du patient âge en s’interessant plus particulierement a la fracture de l’extremite superieure du femur. Une premiere partie concernait l’evaluation en preoperatoire du risque cardiovasculaire, des fonctions cognitives et de la fonction renale. Les auteurs ont recommande une prise en charge pluridisciplinaire et une gestion preoperatoire rationnelle des traitements afin de reduire le risque de confusion. Le delai d’intervention des FESF a ete fixe a 48 h et les modalites de monitorage precisees (monitorage hemodynamique, de la pression arterielle de l’oxygenation et de la temperature). Une technique d’anesthesie n’a pas ete privilegiee pour la chirurgie de la FESF mais une titration des agents anesthesiques a ete recommandee. Les experts ont egalement recommande la mise en place d’un programme de prevention non medicamenteuse de la confusion postoperatoire ainsi qu’une strategie de gestion des episodes confusionnels postoperatoires tels que l’usage d’une benzodiazepine a demi-vie courte ou d’un neuroleptique de derniere generation. Le bloc femoral ou iliofascial ont ete probablement recommandes en postoperatoire a la difference des infiltrations, peu contributives dans ce type de chirurgie.

Objective: Remifentanil, a rapid onset rapid offset synthetic opioid and potent analgesic, is often used for procedural conscious sedation in spontaneous ventilation, especially when delivered in target controlled infusion (TCI), which allows precise titration. We assessed efficacy, tolerance, and adverse events related with the use of remifentanil TCI during various procedures . Design: Prospective, observational . Setting: Two teaching hospitals . Patients: We enrolled 434 patients undergoing procedures suitable for conscious sedation . Interventions: The following procedures considered suitable were included: interventional radiology, gastrointestinal (GI) endoscopy, interventional cardiology, and peripheral dermatology. Sedation options were determined during the preoperative anesthesia assessment . Main outcome measures: Demographics were recorded as well as success rate, remifentanil dosage, pain scores, respiratory or cardiovascular events, and patient and operator satisfaction . Results: The procedure was successful in 429 patients (99 percent), canceled in four patients because of agitation, apnea, desaturation, and converted to general anesthesia in two for major pain. The maximal remifentanil target was around 2-3 ng/ml for most procedures, but it was 3-5 ng/ml for GI endoscopy and urology. A total of 172 patients (40 percent) had bradypnea < 8 min − 1, but only 26 (6 percent) had hypoxemia < 90 percent. Eighteen patients (4 percent) required mandibular luxation, and twelve needed face mask ventilation. There were no major cardiovascular adverse events . Conclusions: Remifentanil TCI is a suitable protocol for procedural sedation, but respiratory depression is a permanent concern. This risk requires equipped environment and competent medical personnel on hand to adjust the target before hypoxemia occurs. Respiratory rate monitoring, based on capnography or thoracic impedance is of a great help in anticipating this threat .

Efficient pain management is essential for postoperative rehabilitation in patients undergoing a tumor resection with an immediate reconstructive surgery. Ultrasound-guided quadratus lumborum block has been described for abdominal or hip surgery, but not for concomitant surgery in the abdomen and the thigh. The paraspinous transmuscular approach has easy landmarks to perform this block. We present a case of a patient undergoing a resection of a sarcoma in the lower limb with an immediate reconstruction with a pedicled vertical designed deep inferior epigastric perforator flap, in whom a successful paraspinous transmuscular quadratus lumborum block for postoperative analgesia was performed.

Introduction Quantitative neuromuscular monitoring is now widely recommended during anesthesia using neuromuscular blocking agents to prevent postoperative residual paralysis and its related complications. We compared the TOF-Watch SX™ accelerometer requiring initial calibration to the TOF-Scan™, a new accelerometer with a preset stimulation intensity of 50 mA not necessitating calibration. Study design This pilot, prospective, observational study included adults undergoing general anesthesia with endotracheal intubation and muscle relaxation, having both arms free during surgery. Accelerometers were set up randomly on each arm. Anesthesia was started with remifentanil and propofol before an intubation dose of atracurium or rocuronium. Train of four stimulation was performed every 15 s. Differences between measures were tested using Student's t -test and agreement assessed by Bland and Altman analysis. Results Thirty-two patients were included. During onset, a mean bias of −26 seconds with a limit of agreement from −172 to +119 seconds was observed between TOF-Watch SX™ and TOF-Scan™ to obtain 0 response to TOF. During recovery, TOF-Scan™ showed a significantly later recovery from 1 response to T4/T1 > 10%, but a bias of 0 minute and limits of agreement from −4 to +4 minutes for T4/T1 > 90% (NS). Conclusion These results suggest a poor agreement between the calibrated TOF-Watch SX™ and the fix intensity TOF-Scan™ for onset and early recovery of relaxation (i.e. deep neuromuscular blockade) but a good agreement for recovery to TOF 90%. Data are not interchangeable between the devices, but both can be useful to detect residual paralysis.

International audience; This review summarises the specific stakes of preoperative, intraoperative, and postoperative periods of patients with coronary artery disease undergoing non-cardiac surgery. All practitioners involved in the perioperative management of such high cardiac risk patients should be aware of the modern concepts expected to decrease major adverse cardiac events and improve short- and long-term outcomes. A multidisciplinary approach via a functional heart team including anaesthesiologists, cardiologists and surgeons must be encouraged. Rational and algorithm-guided management of those patients should be known and implemented from preoperative to postoperative period.

Obesity is becoming an epidemic health problem, and the number of surgical patients with a body mass index of more than 50 kg m−2 requiring anaesthesia is increasing. Obesity is associated with physiopathological changes such as metabolic syndrome, cardiovascular disorders, or sleep apnoea syndrome, most of which improve with weight loss. Regarding pharmacokinetics, volumes of distribution are increased for both lipophilic and hydrophilic drugs. Consequently, doses should be adjusted to total body weight (propofol for maintenance, succinylcholine, vancomycin), or lean body mass (remifentanil, non-depolarizing neuromuscular blocking agent). For all drugs, titration based on monitoring of effects is recommended. To minimize recovery delays, drugs with a rapid offset of action such as remifentanil and desflurane are preferable. Poor tolerance to apnoea with early hypoxaemia and atelectasis warrant rapid sequence induction and protective ventilation. Careful positioning will prevent pressure injuries and minimize rhabdomyolysis which are frequent. Because of an increased risk of pulmonary embolism, multimodal prevention is mandatory. Regional anaesthesia, albeit technically difficult, is beneficial in obese patients to treat postoperative pain and improve rehabilitation. Maximizing the safety of anaesthesia for morbidly obese patients requires a good knowledge of the physiopathology of obesity and great attention to detail in planning and executing anaesthetic management. Even in elective surgery, many cases can be technical challenges and only a step-by-step approach to the avoidance of potential adverse events will result in the optimal outcome.

Bayesian forecasting has been shown to improve the accuracy of pharmacokinetic/pharmacodynamic (PK/PD) models by adding measured values to a population model. It could be done in real time for neuromuscular blockers (NMB) using measured values of effect. This study was designed to assess feasibility and benefit of Bayesian forecasting during a rocuronium target-controlled infusion (TCI). After internal review board (IRB) approval and informed consent, 21 women scheduled for breast plastic surgery were included. Anesthesia was maintained with propofol, alfentanil, and controlled ventilation through a laryngeal mask. Rocuronium was delivered in TCI with Stanpump software and the Plaud population model. The target effect was 50% blockade until insertion of breast prosthesis; thereafter it was set to 0%. Response to train of four (TOF) at adductor pollicis was recorded using a force transducer. In ten patients, drug delivery was based on the population model. In the others, repeated measures values were entered in the software, and the PK model was adjusted to minimize the error in predicted effect. Model precision was compared between groups using mean prediction error and mean absolute prediction error. At target 50%, model accuracy was not improved with Bayesian adjustments; conversely, post-infusion errors were significantly decreased. The first two measures had the most influence on the model changes. Below clinical utility, such adjustments may be used to explore cofactors influencing interindividual and intraindividual variability in NMB dose-response relationship. Similar tools may also be developed for drugs in which a quantitative effect is available, such as electroencephalography (EEG) for hypnotics. Real-time Bayesian forecasting combining measured values of effect with a population model is suitable to guide NMB-agent delivery using Stanpump software.

Endocrine tumors could be defined by their ability to produce structural proteins or hormones common to nervous and endocrine cells. They might induce physiological transforms or outcome adverse events which should be well known in order to prevent or treat them early. The goal of this review was to describe these changes, to describe preoperative assessment, and to discuss intraoperative monitoring and drugs choice based on the literature from the last 30 years. As an example, it should be noticed that: (1) preoperative blood pressure control is essential to prepare phaeochromocytoma for surgery. It should be followed during anaesthesia by intensive fluid load, reversible anaesthetic drugs and rational cardiovascular medications use (as for example remifentanil, sevoflurane, calcium channel blockers and esmolol), and after surgery by narrow clinical and biological monitoring; (2) after medullar thyroid cancer, main adverse events include cervical compressive haematoma and recurrent laryngeal nerve injury as for any thyroid surgery; (3) during pituitary surgery, air embolism might be expected, whereas water dysregulation (diabetes insipidus), corticotroph insufficiency, cerebrospinal fluid (CSF) leak might occur postoperatively. In acromegaly, difficult endotracheal intubation is possible whereas severe Cushing's syndrome may be complicated with hypertensive cardiac failure, infections, thrombosis, delayed cicatrisation; (4) somatostatine analogs are a keystone in carcinoid tumors preoperative and anaesthetic management.

Resume L’anesthesie a objectif de concentration consiste a regler une concentration « cible » a maintenir dans le sang et le systeme nerveux central d’un patient et a confier le calcul des doses correspondantes a un logiciel integre au pousse-seringue. Ce mode d’administration est disponible pour le propofol, le sufentanil et le remifentanil (et bientot pour l’alfentanil). L’anesthesie intraveineuse a objectif de concentration (AIVOC) ne modifie ni les proprietes pharmacologiques des morphiniques ni leurs proprietes pharmacocinetiques mais facilite l’obtention de la concentration minimum necessaire afin de limiter les effets indesirables et l’installation d’une tolerance. Le choix de la concentration cible depend de l’intensite des stimulations douloureuses, du patient, de l’equilibre hypnotique–morphinique et du contexte (duree de perfusion, necessite ou non d’un reveil rapide). Elle doit toujours etre reevaluee apres que les concentrations aient atteint l’equilibre et faire l’objet d’une adaptation a chaque patient et a chaque temps operatoire.

We report a case of a falsely elevated-bispectral index (BIS) during a general anaesthesia combining remifentanil TCI, desflurane and nitrous oxide for an isolated-limb chemotherapy. During surgery, BIS increased and stabilized around 70, with neither residual neuromuscular blockade nor clinical sign of awareness. These high BIS values were attributed to high-electromyographic activity and electric artefacts, such as extracorporeal-circulation machine and tourniquet. At the end of the surgery, the BIS returned to expected values around 50. The patient did not complain of intraoperative recall. This case reminds us that the BIS has some limits as being sensitive to EMG or environment artefacts that should be eliminated before deepening anesthesia. To do so, a decision algorithm is proposed that may be used for all situations of surprising high BIS, taking into account the level of neuromuscular blockade, clinical response to orders and the presence of devices likely to induce electrical or mechanical artefacts.

Resume Introduction En circuit ferme, une fraction expiree choisie d’halogene (Fet) peut etre atteinte en ajustant la fraction delivree (Fd) ou le debit de gaz frais (DGF). L’efficacite de chaque modalite et la consommation d’agent sont evaluees dans cette etude. Patients et methodes Soixante patients (dix par groupe) ont recu, apres induction intraveineuse et intubation, desflurane, sevoflurane ou isoflurane avec 50 % de N 2 O, pour obtenir une Fet egale a une concentration alveolaire minimale (CAM), selon une des modalites suivantes : haut DGF (HDGF) Fd fixe a +20 % de la Fet cible, DGF 10 l/min, puis 1 l/min des la cible atteinte, ouverture du DGF a l’arret de l’halogene ; bas DGF (BDGF) DGF fixe a 1 l/min, Fd maximale, reduite a Fet cible + 20 % des celle-ci atteinte, maintien du DGF a 1 l/min a l’arret de l’halogene. Resultats La Fet cible a ete atteinte chez tous les patients en BDGF en 2,1 ± 0,9 min avec un surdosage de 15 % (isoflurane) a 57 % (sevoflurane), et chez neuf patients sur 30 apres dix minutes en HDGF, sans difference significative entre desflurane et sevoflurane. La consommation d’halogene etait quatre fois plus faible en BDGF. Les delais de decroissance de Fet et d’extubation etaient plus courts dans le groupe HDGF et identiques pour les trois agents. Conclusion Le surdosage de Fd est la methode la plus rapide, reproductible et economique pour atteindre une Fet choisie ou l’augmenter. L’ouverture du DGF reste la methode la plus rapide pour diminuer la Fet a la fin de l’intervention comme en peroperatoire. L’ajustement de Fd et DGF pour augmenter les gradients Fd/Fet neutralise les differences cinetiques entre desflurane et sevoflurane et minimise les differences avec l’isoflurane.

Background Pseudomyxoma peritonei (PMP) is characterized by progressive intraperitoneal accumulation of mucous and mucinous implants, usually derived from a ruptured, possibly malignant mucinous neoplasm of the appendix. Treatment based on complete cytoreductive surgery (CCRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is gaining support. The aim of this study was to identify pre- and perioperative factors of prognostic value. Methods A total of 105 patients (with no residual tumours exceeding 2 mm) were treated with CCRS plus HIPEC based on oxaliplatin. Clinical, radiological, pathological factors and blood markers were analysed to determine their prognostic value for survival. Results Mortality (7·6 per cent) and morbidity (67·6 per cent) were significantly correlated with peritoneal index, pathological grade and blood CA19·9 level. The median follow-up was 48 months. Seven patients died after hospital discharge. Overall and disease-free 5-year survival rates were 80·0 and 68·5 per cent respectively. The Cox model identified only two significant factors impacting on disease-free survival: CA19·9 level and pathological grade. Conclusion CCRS is the most effective treatment for PMP, and adding HIPEC prolongs long-term survival. Further strategies should focus on improving postoperative outcome in extended PMP.

Lluis M. Mir*, Julie Gehl, Gregor Sersa, Christopher G. Collins , Jean-Remi Garbay, Valerie Billard, Poul F. Geertsen, Z. Rudolf , Gerald C. O’Sullivan, Michel Marty Institut Gustave-Roussy, 39 Rue Camille Desmoulins, F-94805 Villejuif Cedex, France CNRS UMR 8121, Institut Gustave-Roussy, F-94805 Villejuif Cedex, France Univ Paris-Sud, UMR 8121, France Department of Oncology, 54B1, University of Copenhagen at Herlev Hospital, Herlev Ringvej 75, DK-2730 Herlev, Denmark Institute of Oncology Ljubljana, Zaloska 2, SI-1000 Ljubljana, Slovenia Cork Cancer Research Centre, Mercy Hospital, Greenville Place, Cork, Ireland

Purpose: To evaluate and confirm efficacy and safety of electrochemotherapy with bleomycin or cisplatin on cutaneous and subcutaneous tumour nodules of patients with malignant melanoma and other malignancies in a multicenter study. Patients and methods: This was a two year long prospective non-randomised study on 41 patients evaluable for response to treatment and 61 evaluable for toxicity. Four cancer centers enrolled patients with progressive cutaneous and subcutaneous metastases of any histologically proven cancer. The skin lesions were treated by electrochemotherapy, using application of electric pulses to the tumours for increased bleomycin or cisplatin delivery into tumour cells. The treatment was performed using intravenous or intratumoural drug injection, followed by application of electric pulses generated by a Cliniporator TM using plate or needle electrodes. Tumour response to electrochemotherapy as well as possible sideeffects with respect to the treatment approach, tumour histology and location of the tumour nodules and electrode type were evaluated. Results: An objective response rate of 85% (73.7% complete response rate) was achieved on the electrochemotherapy treated tumour nodules, regardless of tumour histology, and drug used or route of its administration. At 150 days after the treatment (median follow up was 133 days and range 60‐380 days) local tumour control rate for electrochemotherapy was 88% with bleomycin given intravenously, 73% with bleomycin given intratumourally and 75% with cisplatin given intratumourally, demonstrating that all three approaches were

Resume Une anesthesie generale est d'autant plus profonde que les doses administrees sont hautes, mais la meme profondeur n'est pas obtenue avec les memes doses pour tous les patients, selon leur âge, leur poids, les pathologies sous-jacentes et les medicaments associes… Surveiller la profondeur de l'anesthesie permet donc d'ajuster les doses aux besoins de chaque patient pour eviter a la fois surdosage et sous-dosage. La surveillance clinique porte sur deux composantes principales : la perte de conscience, estimee en temps reel par la perte de reponse aux ordres et a posteriori par l'amnesie de la periode peroperatoire ; la reactivite aux stimuli douloureux, par un mouvement ou par une activation du systeme nerveux autonome. La surveillance pharmacologique consiste a rapporter les effets cliniques des agents anesthesiques aux concentrations estimees au niveau du systeme nerveux central, sachant que la relation qui les relie est stable au cours du temps. La surveillance neurophysiologique mesure certains effets des agents anesthesiques sur le systeme nerveux central. Ces effets portent sur : l'electroencephalogramme (EEG) spontane (analyse bispectrale, entropie, …), les potentiels evoques auditifs (PEA), le tonus neurovegetatif apprecie par la variabilite de la periode cardiaque, la pupillometrie, ou le tonus du sphincter inferieur de l'œsophage, le metabolisme cerebral. L'EEG et des PEA apparaissent aujourd'hui comme les deux signaux neurophysiologiques les plus utilisables en routine. Leurs performances predictives sont bonnes sur la perte de conscience, mais elles predisent mal la reactivite, motrice ou neurovegetative, avant l'application du stimulus douloureux.

Una anestesia general resulta mas profunda cuanto mayores son las dosis administradas. Sin embargo, la misma profundidad no se logra con las mismas dosis en todos los pacientes, ya que depende de su edad, peso, enfermedades subyacentes, farmacos asociados, etc. Asi pues, vigilar la profundidad de la anestesia permite ajustar las dosis a las necesidades de cada paciente para evitar, al mismo tiempo, la sobredosificacion y la infradosificacion. La vigilancia clinica se basa en dos componentes principales: por una parte, la perdida de conocimiento, que se calcula en tiempo real por la perdida de respuesta a las ordenes y, a posteriori, por la amnesia del periodo peroperatorio; por otra, la reactividad a los estimulos dolorosos, estimada gracias a un movimiento o a una activacion del sistema nervioso autonomo. La vigilancia farmacologica consiste en describir los efectos clinicos de los anestesicos a las concentraciones estimadas a nivel del sistema nervioso central; la relacion que los une es estable a lo largo del tiempo. La vigilancia neurofisiologica mide algunos efectos de los anestesicos sobre el sistema nervioso central. Estos efectos se basan en: el electroencefalograma (EEG) espontaneo (analisis biespectral, entropia, etc.), los potenciales provocados auditivos (PPA), el tono neurovegetativo que se calcula por la variabilidad del periodo cardiaco, la pupilometria, o el tono del esfinter esofagico inferior y el metabolismo cerebral. El EEG y los PPA aparecen en la actualidad como los dos signos neurofisiologicos que mas se utilizan de rutina. Sus resultados predictivos son buenos sobre la perdida de conocimiento, pero predicen mal la reactividad, motora o neurovegetativa, antes de la aplicacion del estimulo doloroso.

Resume Objectifs. – Evaluer le taux, la nature, les moyens de reparation utilises et le cout des pannes des machines d’anesthesie liees a leur vieillissement. Type d’etude. – Etude prospective de janvier 1996 a juillet 2000. Materiel et methodes. – La nature (mecanique ou electronique), la circonstance de decouverte (realisation de la checklist, reprise de maintenance et procedure de controle qualite), les moyens de reparation utilises et les couts de maintenance generes par les pannes d’appareils d’anesthesie sont releves et repertories dans une base de donnees sur un parc de 14 appareils d’anesthesie reparti sur 12 sites interventionnels. Resultats. – Sur 31 948 anesthesies realisees, 614 pannes ont ete declarees : 53 % etaient liees a une defaillance mecanique du ventilateur et a des problemes de capteurs ; 40 % ont ete detectees au cours de la checklist et 50 % resolues sur place. Globalement le taux annuel de pannes reste stable sur la periode etudiee et les couts de maintenance annuels s’elevent a environ 10 % de la valeur d’achat. Aucune intervention n’a ete annulee ou reportee suite a une panne d’appareil d’anesthesie. Conclusion. – L’evolution dans le temps du taux de pannes des machines d’anesthesie ne peut representer un critere de remplacement des machines si des procedures de controle qualite et de maintenance rigoureuses existent. 2003 Tous droits reserves. Editions scientifiques et medicales Elsevier SAS

Muscle relaxants and anesthetics are usually associated during intubation. However, their relative role to facilitate the process is not clearly defined. This study was designed to determine, during intubation: i). the relative role of anesthetics and atracurium-induced neuromuscular block and; ii). the effect of different doses of propofol in the presence of complete muscle block.Patients were randomized to four groups and received fentanyl and a standardized anesthetic procedure. Patients from groups high (H; n = 45), medium (M; n = 48) and low (L; n = 47) received 2.5 mg x kg(-1), 2.0 mg x kg(-1), and 1.5 mg x kg(-1) of propofol respectively. Atracurium (0.5 mg x kg(-1)) was then injected and tracheal intubation performed once complete block was achieved at the orbicularis oculi. Patients from group without atracurium (WA; n = 20) received propofol as in group H. Intubation was performed at the expected onset time of action of atracurium.Using the same dose of propofol, the incidence of good or excellent intubating conditions was 35% without atracurium and 95% with atracurium (P0.0001). In patients receiving atracurium, clinically acceptable intubating conditions were more frequently achieved in groups receiving the highest propofol doses (group H or M vs group L; P0.03).Our study confirms the interaction between anesthesia and muscle relaxation to produce adequate intubating conditions. In the conditions described, intubating conditions were more dependent on atracurium-induced neuromuscular blockade than on anesthetics, but both atracurium and propofol improved intubating conditions.

Background: Complete cytoreductive surgery (CCRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is on the verge of becoming the gold standard treatment for selected patients presenting peritoneal metastases (PM) of colorectal origin. PM is scored with the peritoneal cancer index (PCI), which is the main prognostic factor. However, small bowel (SB) involvement could exert an independent prognostic impact. Aim: To define an adequate cut-off for the PCI and to appraise whether SB involvement exerts an impact on this cut-off. Patients and methods: Patients (n ¼ 139) treated with CCRS plus HIPEC were prospectively verified and retrospectively analyzed. One hundred presented with SB involvement of different extents and at different locations. Results: All the patients with a PCI � 15 exhibited SB involvement. Five-year overall survival was 48% when the PCI was

SUMMARY Use of the cell saver in oncologic surgery is controversial because of the risk of reinfusion of cancer cells remaining in the packed erythrocytes. Experimental and clinical studies have indeed confirmed the presence of residual cancer cells in packed red cells. However, six clinical studies with a limited number of patients showed no metastatic spread after processing of the blood with a cell saver. The adjunctive use of a leukocyte depletion filter (LDF) greatly reduces the number of cancerous cells in the pack whereas irradiation of the pack with 50 Gy destroys all the cancer cells. Strictly speaking, the stringent application of this safety principle would require use of a cell saver only in conjunction with an irradiator. Studies indicate that cancer cell seeding from infiltrative tumors seems to be greater than that observed when a cell saver is used. In the final analysis, we feel that it is reasonable to use the cell saver in oncologic surgery, if possible with a leukocyte filter, not only in cases of unexpected bleeding risk but also during scheduled procedures with a high risk of massive blood loss.

Resume La surveillance de la profondeur de lˈanesthesie par lˈelectroencephalogramme (EEG) a ete proposee pour completer la surveillance clinique et guider lˈajustement des doses. Cette revue decrit les principales caracteristiques de lˈEEG spontane et les techniques dˈanalyse automatique du trace. Elle reprend les effets de chaque classe dˈagent anesthesique sur lˈEEG et sur les parametres calcules par lˈanalyse automatique, chez lˈadulte et chez lˈenfant, ainsi que les correlations entre ces parametres et les signes cliniques attendus au cours dˈune anesthesie generale (perte de conscience et de memorisation, absence de mouvement et stabilite neurovegetative malgre les stimulations chirurgicales). A ce jour, la technique dˈanalyse offrant la meilleure correlation est lˈanalyse bispectrale, dont le resultat final dans les moniteurs commercialises est lˈindex bispectral ou BIS™. Les interets, indications cliniques et limites du BIS™ en anesthesie et en reanimation, sont detailles et commentes en se basant sur une analyse des publications recentes.

Resume Objectifs : Evaluer globalement la notoriete et les besoins de formation a l’anesthesie intraveineuse a objectif de concentration (Aivoc), etablir un premier bilan de l’utilisation du dispositif Diprifusor TCI™. Evaluer, aupres de medecins anesthesistes formes, l’apport de sessions de formations specifiques, ainsi que l’impact de ce nouveau mode d’administration dans la pratique au bloc operatoire. Type d’etude : Deux enquetes nationales prospectives durant le premier trimestre 1999. Methodes : Trois cents medecins anesthesistes representatifs de l’ensemble des medecins anesthesistes, et 336 medecins anesthesistes identifies comme ayant participe a une formation. Resultats : La notoriete de l’Aivoc est globalement importante et plus marquee en secteur public qu’en secteur prive. Pres des 3/4 des medecins anesthesistes jugent necessaire une formation specifique, mais quatre sur dix pratiquent l’Aivoc sans avoir recu de formation prealable. A l’issue d’une formation specifique, neuf anesthesistes sur dix utilisent l’Aivoc et conseilleraient cette formation a leurs confreres, bien que le nombre et la diversite des anesthesies observes lors des sessions aient ete juges comme insuffisants. Les principales difficultes rencontrees lors des premieres utilisations concernent le choix des concentrations cibles et la gestion des interactions medicamenteuses. La familiarisation a la technique semble rapide (moins de 20 anesthesies). Bien que l’experience soit encore limitee ( Conclusions : L’Aivoc est percue comme une technique innovante necessitant une formation specifique. Ce premier bilan des formations dispensees est favorable mais il existe encore des attentes en terme de complement de formation.

Background The optimal primary treatment for posterior pharyngeal wall tumors remains controversial. Methods To assess the relevance of surgical treatment from a functional and oncologic point of view, we reviewed the cases of 77 patients surgically treated between 1984 and 1995. Among them 23 had been previously irradiated. Fifty-five patients underwent a conservative surgery (CS) sparing the larynx; 19 direct closures, 6 reconstructions of the posterior wall with a thoracic myocutaneous flap, 15 with a platysma flap, and 15 with a free forearm flap were performed. Twenty-two patients underwent radical surgery (RS). All previously untreated patients had postoperative radiotherapy. The functional assessment concerned the CS group. Oncologic results, especially local control and survival were studied for the whole group. Results Of the 55 patients who underwent CS, 53 (96%) had their canula and 49 (89%) their feeding tube removed. At 1 year, in the platysma and free forearm groups, 21 of the 24 assessable patients were back to exclusive oral intake. For patients treated by primary surgery followed by radiotherapy, the rate of local failure was 11% (18% for tumors greater than 4 cm), and the 5-year survival rate was 35%. For patients who had previous radiotherapy, the rates were, respectively, 52% and 16%. Conclusion The satisfactory functional results, caused by the improvement of reconstructive procedures, allow conservative surgery even in the case of large tumors. Oncologic results, especially local control, suggest that primary surgery followed by radiotherapy is effective for the treatment of posterior wall cancer. The oncologic results of surgery in a previously irradiated area are poor, and CS is not recommended in these cases. © 2001 John Wiley & Sons, Inc. Head Neck 23: 80–86, 2001.

Resume Objectifs : L'autotransfusion peroperatoire par recuperation de sang epanche dans le champ operatoire, realisable par les dispositifs de type Cell Saver™, est controversee en chirurgie carcinologique car elle expose au risque de reinjection de cellules tumorales dans la circulation. Cette mise au point a pour but de decrire l'etat actuel des connaissances concernant ce risque et les moyens de le minimiser. Acquisition des donnees : La revue bibliographique a ete faite en interrogeant la banque de donnees PubMed (http//nbci.nlm.nih.gov) de 1968 a 2000. Les mots cles ont ete : intraoperative blood salvage, blood transfusion, autologous, cancer. Les cas cliniques n’ont pas ete retenus. Selection des travaux : Les etudes decrites etaient cliniques (patients operes) ou experimentales (analyse in vitro de sang volontairement contamine). Elles portent sur le nombre de cellules tumorales dans le sang recupere et dans le sang reinjecte avec ou sans traitement supplementaire. Dans tous les cas, les resultats obtenus avec Cell Saver etaient compares soit aux donnees de la litterature soit a d'autres patients des memes equipes (etudes cas-temoins), mais il n’existe aucune etude randomisee rigoureuse. Synthese des resultats : Toutes les etudes, experimentales ou cliniques, confirment la presence de cellules tumorales dans le sang recupere comme dans le sang reinjecte. Malgre cela, l'utilisation du Cell Saver dans six etudes cliniques, avec des effectifs de 20 a 55 patients, n’a pas induit d’efflorescence metastatique avec des reculs de 12 a 60 mois. L’adjonction d’un filtre a leucocytes reduit de maniere importante la quantite de cellules tumorales presentes dans les concentres globulaires rouges (CGR), tandis que l’irradiation de ce culot a 50 Gy inactive definitivement leurs divisions cellulaires. Par ailleurs, il existe en l'absence de toute recuperation de sang dans le champ operatoire un essaimage permanent issu naturellement des tumeurs. Cet essaimage apparait quantitativement superieur a celui realise avec l’utilisation du Cell Saver (surtout en presence d'un filtre a leucocytes), mais tres peu de donnees sont disponibles et il existe probablement de grandes variations selon le type de tumeur et la technique chirurgicale. Conclusion : Il nous semble possible d’utiliser le Cell Saver en chirurgie carcinologique, non seulement en cas d'hemorragie massive imprevue, survenant au cours d’une intervention (deja admis par le consensus), mais egalement en chirurgie programmee a haut risque d’hemorragie massive. L'interposition d'un filtre a leucocytes de derniere generation apparait hautement souhaitable.

Resume Objectif : Evaluer l’utilite du monitorage de l’index bispectral de l’EEG (BIS™) dans le diagnostic differentiel et le traitement des hypertensions au cours des cœlioscopies. Type d’etude : Etude preliminaire sans randomisation. Patients : 15 patients beneficiant d’une cœliochirurgie. Methodes : Aivoc de propofol et bolus iteratifs de fentanyl pour maintenir des concentrations de fentanyl superieures a 2 ng·mL–1 au site d’action selon le modele pharmacocinetique de Scott. La pression arterielle moyenne (PAM) et la frequence cardiaque (FC) ainsi que le BIS™ ont ete enregistres simultanement. Un BIS™ compris entre 40 et 60 et une PAM comprise entre 80 et 120 % des valeurs de preinduction ont ete maintenus en se fondant sur une matrice de decision similaire a celle de Gurman. Resultats : La PAM a augmente apres l’insufflation du pneumoperitoine alors que les variations de la FC et du BIS™ n’ont pas ete significatives. Discussion : Les elevations de pressions arterielles peuvent etre provoquees par d’autres facteurs que la douleur au cours des cœlioscopies. Une anesthesie inadequate doit etre eliminee avant de retenir les autres mecanismes. La stabilite du BIS™ Conclusion : L’association du monitorage de la PAM et du BIS™ dans une matrice de decision comme celle de Gurman permet de mieux orienter les choix therapeutiques lors des poussees hypertensives au cours des cœlioscopies.

Resume Cette observation decrit la prise en charge perioperatoire d'un patient atteint d'une tumeur carcinoide digestive avec metastases hepatiques, et syndrome carcinoide clinique preoperatroire. Le monitorage de l’index bispectral de l’EEG (BIS TM ), associe a la surveillance hemodynamique habituelle, a permis de rapporter les episodes hypertensifs peroperatoires au syndrome carcinoide et non a une insuffisance de la profondeur de l’anesthesie, ce qui a permis un traitement adapte par un analogue de la somatostatine.

Resume Objectif Evaluer l'incidence et les causes des pannes des appareils d'anesthesie identifiees pendant la check-list d'ouverture de la salle ou survenues pendant l'anesthesie. Type d'etude Enquete prospective d'aout 1995 a septembre 1997. Materiel Fiches de check-list et fiches de pannes. Methodes Les pannes des appareils d'anesthesie ont ete colligees et entrees dans une base de donnees. La nature de chaque panne et les moyens mis en œuvre pour la traiter ont ete analyses. Resultats Sur un nombre theorique de 5096 fiches, 3926 (77 %) ont ete remplies au cours de la check-list, ou en cas de panne pendant l'anesthesie. Au total, 233 incidents ont ete declares soit 4,5 %. Les pannes identifiees pendant la check-list preoperatoire (n = 96, soit 2,4 % des 3 926 fiches remplies) etaient le plus souvent d'origine mecanique et concernaient principalement le debitmetremelangeur (35 %). Les pannes survenues pendant l'anesthesie (n = 137) etaient le plus souvent d'origine electronique et concernaient le ventilateur (27 %) et le moniteur de surveillance (57 %). Dans plus de la moitie des cas, il a ete possible de corriger l'anomalie sur place, par un soignant specialement forme a cette tâche. Moyennant la mise a disposition de materiel de remplacement immediatement disponible, aucune intervention n'a ete reportee ou deplacee du fait d'une panne de materiel d'anesthesie. Conclusions Ce travail souligne l'interet de la check-list et du recueil systematique des anomalies detectees. La presence d'un soignant referent technique permet de resoudre immediatement un bon nombre de problemes et d'assurer ainsi un soutien technique immediat.

During balanced anaesthesia sufentanil may be difficult to use, as the required doses change over time depending on the patient and the noxious stimuli. Patient adjustment may be improved by using pharmacokinetic simulations that predict the concentration achieved in the body. In the first case report, sufentanil was given manually as repeated boluses, then by infusion. As haemodynamic status remained unstable, a simulation of the sufentanil concentration time course was started during the case. It showed that instability had pharmacokinetic explanation and allowed to determine the adequate sufentanil concentrations (0.30-0.40 ng.mL-1 + N2O + isoflurane 0.8-1 vol% for abdominal surgery). However, adjusting the doses manually required numerous human actions. In the second case, sufentanil was given as a computer-controlled infusion. The adequate concentrations were determined (0.15-0.20 ng.mL-1 + N2O + isoflurane 0.4 vol% for peripheral surgery in an aged cardiac patient). They were maintained with a limited number of human actions and resulted in satisfactory haemodynamic stability.

We report the successful treatment of a 66-year-old man with failure of conventional local and general treatments for Kaposi sarcoma. He had a poor quality of life because of large ulcerated lesions on both legs. After the first electrochemotherapy session, the largest and the most painful lesions were cleared. Later on, repetitive electrochemotherapy sessions combined with the alternate use of imiquimod application led to an excellent local control with no secondary effect. This case demonstrates that electrochemotherapy can be safely and successfully repeated, with persistent excellent antitumour effects.

To test the efficacy of the LMA in patients with previous oral or cervical radiotherapy, without upper airway obstruction.In nine patients after oral or cervical radiotherapy, efficiency of ventilation was assessed after induction of general anaesthesia and LMA insertion. Fibreoptic examination through the tube was performed to check the position of LMA.In patients who had had oral radiotherapy, all five had limited mouth opening and in two, LMA insertion was difficult but permitted good ventilation. In the four patients who had had cervical radiotherapy, LMA insertion was easy but, in two, the lungs were difficult to ventilate and, in two, the lungs could not be ventilated and orotracheal intubation was required.In patients with limitation of mouth opening after oral radiotherapy, LMA may represent an alternative to tracheal intubation. In patient with cervical sclerosis after radiotherapy; the use of LMA should be avoided.

Resume La perfusion a objectif de concentration est une nouvelle modalite d'administration des agents IV par laquelle le praticien prescrit une concentration cible pour produire un effet recherche. La conversion de cette concentration en quantite d'agent administre est assuree par un module de calcul qui commande un dispositif de perfusion et lui impose un debit adapte. Apres avoir ete longtemps reservee a quelques equipes de recherche, cette modalite d'administration se trouve en 1997 au seuil d'une diffusion beaucoup plus large, grâce a la mise sur le marche de dispositifs de perfusion integrant un module d'administration a objectif de concentration. C'est dans ce contexte que cette mise au point vise, apres avoir justifie la perfusion a objectif de concentration au regard des autres modalites d'administration des agents IV, a clarifier les bases pharmacocinetiques qui ont permis d'elaborer les logiciels de commande des pousse-seringues et de decrire dans le detail le fonctionnement de ces dispositifs. A cette occasion, les aspects reglementaires sont abordes. Enfin les applications cliniques actuelles et futures de l'anesthesie IV a objectif de concentration (AIVOC) sont developpees.

Intermittent vascular exclusion of the liver (IVEL) combines clamping of the hepatic pedicle with clamping of the main hepatic veins without interruption of caval flow. In this retrospective study, eight cases of total IVEL and eight of partial IVEL were analysed (involving only the middle and left hepatic veins) during major hepatectomy for malignant tumours. Liver parenchyma was pathological in nine cases. IVEL was feasible in 16 of the 18 attempts and was efficient in reducing bleeding during hepatectomy in 15 cases. Mean duration of IVEL was 60.2 (range 37–140) min, mean blood loss was 1230 (range 300–2800) ml and there were no postoperative complications related to the procedure. The major advantages of this technique of liver vascular exclusion (good tolerance and possibility of long duration) merit its inclusion in the list of different clamping techniques available for use during hepatectomy.

Background Retrospective studies have suggested that regional analgesia combined with general anaesthesia could decrease cancer recurrence. The purpose of this study was to assess the influence of regional analgesia on recurrence-free (RFS) and overall survival in patients undergoing major intra-abdominal surgery for cancer. Method Patients previously included in a prospective randomized study comparing two postoperative techniques of analgesia were retrospectively studied. The EP group received general anaesthesia with bupivacaine thoracic epidural analgesia and the SC group received general anaesthesia with fentanyl followed by continuous subcutaneous morphine. Results One hundred and thirty-two patients were analyzed (63 and 69 in SC and EP group, respectively) with a 17-year-median follow-up. After 5 years, RFS was 43% [95% CI: 32%–55%] in EP group and 24% [95% CI: 15%–36%] in SC group, but the difference did not reach statistical significance for RFS nor for overall survival ( P = 0.10 and 0.16 respectively). Using multivariable analysis over the whole follow-up period, the type of analgesia was not a statistically significant predictive factor for RFS (EP/SC, HR = 1.3 [95% CI: 0.8–2.0%]). The anaesthesia effect changed moderately over the follow-up and HR for overall survival (EP/SC) reached statistical significance after 5, 6 and 8 years. Conclusion Despite a trend in favour of the epidural, this retrospective review of patients included in a previous randomized study failed to demonstrate a statistically significant association between the perioperative analgesia and RFS after abdominal surgery for cancer. The duration of follow-up may have an impact on the analgesia effect on survival.

Flexible fiberoptic bronchoscopy (FFB) is a major diagnostic tool commonly used in intensive care unit (ICU). However, it generates discomfort and pain and can worsen respiratory and/or hemodynamic condition of critically ill patients. Remifentanil is an ultrashort-acting opioid drug that has been shown to provide effective sedation for painful procedures in spontaneous breathing patients. The aim of this study is to evaluate the safety and efficacy of sedation with remifentanil target-controlled infusion (Remi-TCI) in patients with spontaneous ventilation undergoing FFB in ICU.Monocentric prospective study. All patients received Remi-TCI with initial effect-site target concentration of 2 ng/mL, progressively titrated according to their comfort and sedation. Respiratory and hemodynamic parameters were assessed before, during, and after the procedure, as well as comfort, level of sedation, FFB conditions, and recovery patterns. Global Remi-TCI data and potential complications of the procedure were also recorded.Fourteen patients were included. FFB was successful in all patients with good conditions (sedation, global comfort, and cough). No severe hemodynamic or respiratory complications occurred during procedure. Maximum target concentration and total dose of remifentanil were 2.5 ng/mL (2-4 ng/mL) and 1.4 μg/kg (0.7-2.4 μg/kg), respectively, over 10 min. Patients reported low level of pain and good satisfaction with the procedure.FFB under sedation with Remi-TCI seems to be safe and effective in critically ill patients with spontaneous ventilation. Such results could be the first step towards wider use of Remi-TCI in patients experiencing awkward and/or painful procedures in this setting.

Potential benefits of regional analgesia in reduction of cancer recurrence have been reported for breast and prostate cancer. The aim of this study was to evaluate the influence of regional analgesia on recurrence-free survival and overall survival in patients with advanced-stage ovarian cancer (ASOC) following complete cytoreduction.This is a retrospective study of 104 patients who had undergone complete cytoreduction for ASOC between 01/2007 and 12/2009: 51 with patient controlled epidural analgesia (PCEA) and 53 without PCEA.No significant difference was found between the two groups in terms of overall survival, while there was a trend in favour of PCEA for disease free survival.In our study, regional analgesia had no clear impact on cancer recurrence. More studies on this subject are warranted in order to determine the possible impact of regional analgesia on ASOC.

Introduction L’anesthesie intraveineuse a objectif de concentration (AIVOC) est une modalite d’administration d’agent anesthesique a disposition des medecins anesthesistes reanimateurs (MAR) depuis plus d’une quinzaine d’annees. La derniere evaluation de la formation et pratique de l’AIVOC a ete realisee juste apres la mise a disposition du materiel, encore peu diffuse et utilise a l’epoque [1] . Nous avons evalue les connaissances et pratiques actuelles en matiere d’AIVOC. Materiel et methodes Une enquete nationale, via GoogleDoc, a ete menee entre decembre 2013 et fevrier 2014 a partir d’un questionnaire online (78 questions) elabore et valide par un comite d’expert puis diffuse aux praticiens hospitaliers, aux medecins liberaux et internes. Les objectifs etaient d’apprecier la connaissance theorique globale de l’AIVOC, d’evaluer sa diffusion, sa disponibilite et de dresser un bilan de son utilisation. L’analyse du questionnaire a ete realisee via le logiciel Sphinx iQ (v 6.3.0.8). Resultats Mille trois reponses (62,5 % d’etablissements publics, 25 % d’internes) ont ete recueillies. Le dispositif etait disponible dans 93 % des structures avec une utilisation plus d’une fois par semaine par 46 % des MAR. Seuls 3,4 % declarent ne jamais l’utiliser. Le propofol (90 %) et le remifentanil (81,6 %) etaient les agents les plus utilises contrairement au sufentanil (35 %), avec la pratique d’une double AIVOC par un tiers des MAR. Les principales indications rapportees etaient liees : au produit (anesthesie totale intraveineuse au propofol (22 %)), aux aspects techniques (sites depourvus d’halogene (55,1 %)), aux facultes de titration de l’AIVOC (anesthesie en ventilation spontanee (52 %), sujets âges (64 %), fragiles ou hemodynamiquement instables (18 %)), a la chirurgie (thyroide (38,7 %), scoliose (63,8 %)). 75 % des MAR l’utilisaient pour des sedations (endoscopie, radiologie interventionnelle). En revanche, l’AIVOC reste peu utilisee en reanimation (5,5 %). Sa non-utilisation etait attribuee au defaut de formation et a la reticence des IADE (16,4 %), au cout et gaspillage (11 et 19 %), a la longueur de l’acte et l’obesite (41,4 %). Seuls 5 % des MAR se declarent insuffisamment formes pour l’utiliser. Dans l’AIVOC au propofol le modele de Schnider est le plus utilise (63,3 %) en ciblant le site d’action (80,6 %). Les connaissances restent cependant imparfaites car la moitie des MAR ne connaissent pas precisement les covariables associees aux modeles : 50 % pensent a tort que l’âge influence le modele de Marsh alors que 30 % pensent qu’il n’intervient pas dans le modele de Schnider. Seuls 11 % connaissent le modele de Gepts. Les MAR interroges demandent de nouveaux modeles pharmacologiques, une meilleure disponibilite du materiel et 25 % reclament encore des formations complementaires. Discussion Malgre des connaissances theoriques encore imparfaites, on note depuis 2001 une familiarisation et une diffusion de l’AIVOC en France. Les praticiens restent en attente de formations supplementaires et du developpement de nouveaux modeles pharmacologiques qui permettraient sa plus large utilisation. Ces resultats doivent etre relativises car les repondants (dont un fort pourcentage d’internes) ne sont pas representatifs de la population des anesthesistes francais.