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The National Surgical Quality Improvement Program Myocardial InfarctionCardiac Arrest (NSQIP MICA) calculator and the Revised Cardiac Risk Index (RCRI) were derived using currently outdated methods of diagnosing perioperative myocardial infarctions. We tested the external validity of these tools in a setting of a systematic perioperative cardiac biomarker measurement.Analysis of routinely collected data nested in the Vascular Events In Noncardiac Surgery Patients Cohort Evaluation Study. A consecutive sample of patients ≥45 yr old undergoing in-hospital noncardiac surgery in a single tertiary care centre was enrolled. The predictive performance of the models was tested in terms of the occurrence of major cardiac complications defined as a composite of a nonfatal myocardial infarction, a nonfatal cardiac arrest, or a cardiac death within 30 days after surgery. The plasma concentration of high-sensitivity troponin T was measured before surgery, 6-12 h after operation, and on the first, second, and third days after surgery. Myocardial infarction was diagnosed according to the Third Universal Definition.The median age was 65 (59-72) yr, and 704/870 (80.9%) subjects were male. The primary outcome occurred in 76/870 (8.7%; 95% confidence interval [CI], 6.9-10.8%) patients. The c-statistic was 0.64 (95% CI, 0.57-0.70) for the NSQIP MICA and 0.60 (95% CI, 0.54-0.65) for the RCRI. Predicted risks were systematically underestimated in calibration belts (P0.001). The RCRI and the NSQIP MICA showed no clinical utility before recalibration.The NSQIP and RCRI models had limited predictive performance in this at-risk population. The recently updated version of the RCRI was more reliable than the original index.

Background : Persistent post-surgical pain and associated disability are common after a traumatic fracture repair. Preliminary evidence suggests that patients' beliefs and perceptions may influence their prognosis. Methods We used data from the Fluid Lavage of Open Wounds trial to determine, in 1560 open fracture patients undergoing surgical repair, the association between Somatic PreOccupation and Coping (captured by the SPOC questionnaire) and recovery at 1 yr. Results Of the 1218 open fracture patients with complete data available for analysis, 813 (66.7%) reported moderate to extreme pain at 1 yr. The addition of SPOC scores to an adjusted regression model to predict persistent pain improved the concordance statistic from 0.66 to 0.74, and found the greatest risk was associated with high (≥74) SPOC scores [odds ratio: 5.63; 99% confidence interval (CI): 3.59–8.84; absolute risk increase 40.6%; 99% CI: 30.8%, 48.6%]. Thirty-eight per cent (484 of 1277) reported moderate to extreme pain interference at 1 yr. The addition of SPOC scores to an adjusted regression model to predict pain interference improved the concordance statistic from 0.66 to 0.75, and the greatest risk was associated with high SPOC scores (odds ratio: 6.06; 99% CI: 3.97–9.25; absolute risk increase: 18.3%; 95% CI: 11.7%, 26.7%). In our adjusted multivariable regression models, SPOC scores at 6 weeks post-surgery accounted for 10% of the variation in short form-12 physical component summary scores and 14% of short form-12 mental component summary scores at 1 yr. Conclusions Amongst patients undergoing surgical repair of open extremity fractures, high SPOC questionnaire scores at 6 weeks post-surgery were predictive of persistent pain, reduced quality of life, and pain interference at 1 yr. Clinical trial registration NCT00788398.

Background The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. Existing risk assessment tools are not valid for use in this population because the pattern of risk for poor outcomes differs from high-income countries. The objective of this study was to derive and validate a simple, preoperative risk stratification tool to identify African surgical patients at risk for in-hospital postoperative mortality and severe complications. Methods ASOS was a 7-day prospective cohort study of adult patients undergoing surgery in Africa. The ASOS Surgical Risk Calculator was constructed with a multivariable logistic regression model for the outcome of in-hospital mortality and severe postoperative complications. The following preoperative risk factors were entered into the model; age, sex, smoking status, ASA physical status, preoperative chronic comorbid conditions, indication for surgery, urgency, severity, and type of surgery. Results The model was derived from 8799 patients from 168 African hospitals. The composite outcome of severe postoperative complications and death occurred in 423/8799 (4.8%) patients. The ASOS Surgical Risk Calculator includes the following risk factors: age, ASA physical status, indication for surgery, urgency, severity, and type of surgery. The model showed good discrimination with an area under the receiver operating characteristic curve of 0.805 and good calibration with c-statistic corrected for optimism of 0.784. Conclusions This simple preoperative risk calculator could be used to identify high-risk surgical patients in African hospitals and facilitate increased postoperative surveillance. Clinical trial registration NCT03044899.

A common research question in perioperative haemodynamics research concerns the assessment of whether a new measurement device can replace an existing device (often referred to as method comparison studies). Typically, a new measurement method is being compared with an established reference method (unfortunately often referred to as the ‘gold standard’). In a recent issue of the journal, Biais and colleagues reported the comparison of two cardiac output measurement devices, one based on pulse wave transit time (i.e. the new devices) and the other one based on transthoracic echocardiography (i.e. the reference method ‘gold standard’). The study concluded that devices were not interchangeable and that the new device cannot guide haemodynamic interventions in critically ill patients. Their conclusion was based on observing percentage errors exceeding the limits of 30%, suggested by Critchley and Critchley.

In their recent paper, Kieser et al. compared the predictive performance of EuroSCORE against its successor EuroSCORE II in a consecutive series of isolated coronary artery bypass graft patients with total arterial grafting by a single surgeon. Although comparative validation studies such as these are extremely important, we have a number of concerns on the study design and analysis, for which we will highlight only a couple of issues, that question how anyone can meaningfully interpret their findings.

International audience; Background. The bleeding impact of dual antiplatelet therapy (DAPT), aspirin and clopidogrel, maintained until coronary artery bypass graft surgery (CABG), is still a matter of debate. The lack of preoperative antiplatelet activity measurement and heterogeneity of antifibrinolytic protocols in prior studies make the conclusions questionable. The aim of this prospective study was to determine, after preoperative antiplatelet activity measurement, if the maintenance of DAPT until CABG increases bleeding in patients treated with tranexamic acid (TA).Methods. This observational study included 150 consecutive patients, 89 treated with aspirin and 61 treated with DAPT, undergoing a first-time planned on-pump CABG with TA treatment. Antiplatelet activity was measured with platelet aggregation tests and quantification of VASP phosphorylation. Postoperative bleeding at 24 h was recorded and propensity score analysis was performed.Results. Based on VASP assay, 54% of patients showed high on-clopidogrel platelet activity inhibition. Postoperative bleeding at 24 h increased by 22% in the DAPT group, compared with the aspirin group (680 [95% CI: 360-1670] vs 558 [95%CI: 267-1270] ml, P

Un biomarqueur permet d’etablir un diagnostic de maladie, d’evaluer sa severite, d’estimer un risque ou de guider une intervention therapeutique (theranostique). Bien que des progres tres importants aient ete accomplis dans la standardisation de la methodologie des essais cliniques, beaucoup reste a faire dans le domaine de l’evaluation des biomarqueurs. La performance diagnostique ou pronostique d’un biomarqueur peut etre evaluee a l’aide de la sensibilite, de la specificite, et des valeurs predictives positive et negative, dont l’influence de la prevalence doit etre prise en compte. L’utilisation des rapports de vraisemblance permet de prendre en compte l’information existante (probabilite pretest) et l’amelioration apportee par le biomarqueur. La courbe ROC (receiver operating characteristic) et son aire sous la courbe (AUCROC) sont importantes pour une appreciation globale du biomarqueur et le choix d’un seuil. La definition d’une zone d’incertitude et les methodes de reclassification constituent des approches modernes de l’evaluation des biomarqueurs, qui ne doivent pas faire negliger le critere de qualite essentiel qu’est la puissance statistique. De fait, toute etude diagnostique doit inclure un calcul a priori du nombre de patients a inclure. Les etudes diagnostiques restent encore trop souvent conduites avec des methodologies et des analyses statistiques inadaptees, limitant la validite et la robustesse des resultats observes, et donc leurs valeurs cliniques. Les investigateurs doivent les prendre en compte dans la construction de leurs etudes, les redacteurs en chef et les relecteurs des journaux quand ils les analysent et les acceptent pour publication, et les lecteurs quand ils en prennent connaissance.

Recent publications have reported high incidence of perioperative complications in patients with drug-eluting stent (DES). The recommendations for bare-metal stents (BMS) are not applicable to DES. In fact, large evidence-based studies are lacking on which to base a consensus for the perioperative management of patients with DES. The aim of the present study is to evaluate the postoperative cardiac risk associated with DES.Prospectively collected data were examined for the rate of postoperative cardiac complications in 96 consecutive patients with DES who underwent digestive, urologic, orthopaedic, or vascular surgery. The average delay between revascularization and non-cardiac surgery was 14 (11) months (extremes 1 week and 36 months). The occurrence of postoperative troponin release (troponin Ior =0.15 ng ml(-1)) and the rate of in-stent thrombosis were analysed.Twelve patients (12%) presented a postoperative troponin release, without EKG abnormalities in 10 cases (83%). Two patients (2%) developed an in-stent thrombosis. None of the patients had excessive postoperative blood loss.Patients with DES are at higher risk of postoperative cardiac complications. Nevertheless, the specific thrombotic complications of the DES were uncommon in this series and this is in contrast to previous alarming reports. A balanced perioperative management of anti-platelet agents, considering both risk for bleeding and risk of thrombotic complications, in patients with DES, is associated with a low risk of thrombosis in the postoperative period. The rate of cardiac complications remains high in these patients due to co-morbidities.

We read with interest the study by Solomon and colleagues that used a large registry cohort to develop and internally validate a risk score to predict the 10-year risk of cardiovascular disease in patients with rheumatoid arthritis. However, there are a number of issues we raise that question the potential usefulness of the risk score.

Evaluating a prediction model using a separate dataset from which the model was developed is a crucial step in assessing its predictive performance, often referred to as external validation. The recent study by Tetrault and colleagues modified their previous prediction model by omitting one of the predictors and then re-fitting the model on the original development data from 12 sites from North America. The modified prediction model was subsequently evaluated on a larger international cohort from the AOSpine CSM-I trial. Whilst it is encouraging to see authors carrying out such external validation studies, there are concerns in the analysis which need highlighting.

Objective Intraoperative haemodynamic optimization based on fluid management and stroke volume optimization (Goal Directed Fluid Therapy [GDFT]) can improve patients’ postoperative outcome. We have described a closed-loop fluid management system based on stroke volume variation and stroke volume monitoring. The goal of this system is to apply GDFT protocols automatically. After conducting simulation, engineering, and animal studies the present report describes the first use of this system in the clinical setting. Study design Prospective pilot study. Patients Patients undergoing major surgery. Methods Twelve patients at two institutions had intraoperative GDFT delivered by closed-loop controller under the direction of an anaesthesiologist. Compliance with GDFT management was defined as acceptable when a patient spent more than 85% of the surgery time in a preload independent state (defined as stroke volume variation Results Closed-loop GDFT was completed in 12 patients. Median surgery time was 447 [309–483] min and blood loss was 200 [100–1000] ml. Average cardiac index was 3.2 ± 0.8 l/min/m2 and on average patients spent 91% (76 to 100%) of the surgery time in a preload independent state. Twelve of 12 patients met the criteria for compliance with intraoperative GDFT management. Conclusion Intraoperative GDFT delivered by closed-loop system under anaesthesiologist guidance allowed to obtain targeted objectives in 91% of surgery time. This approach may provide a way to ensure consistent high-quality delivery of fluid administration and compliance with perioperative goal directed therapy.

This editorial refers to ‘Do observational studies using propensity score methods agree with randomized trials? A systematic comparison of studies on acute coronary syndrome’†, by I.J. Dahabreh et al. , on page 1893 Evaluating the effectiveness of a therapeutic intervention is ideally carried out in the setting of a randomized controlled trial (RCT). Patients are randomly allocated to the experimental and control groups ensuring that observed, pre-treatment key prognostic characteristics, but also unobserved patient characteristics, are balanced between the treatment groups, minimizing the variability in patient characteristics. Providing a sufficient number of patients have been randomized, this balance in observed and unobserved pre-treatment characteristics between the groups enables unbiased conclusions about the treatment effect to be drawn. There may, however, be instances where randomization is not possible due to, for example, ethical reasons (e.g. emergency surgery,1 transplantation2) or because it is impractical (e.g. rare events, financial reasons). When it is not possible to conduct an adequately powered RCT, observational studies are often carried out to examine and infer treatment effects. In addition, treatment effects observed in RCTs that involve highly selective populations are often examined in different patient populations and settings in observational studies. However, in observational studies, investigators have no control over treatment assignment, which is often part of a patient's routine medical care. In these instances, it is likely that potentially large systematic differences (typically confounding by indication) in observed patient characteristics could lead to large, biased, and ultimately misleading estimates of treatment effect. Propensity scores are increasingly being used to reduce the impact …

Context Of the 200 million adults worldwide who undergo noncardiac surgery each year, more than 1 million will die within 30 days. Objective To determine the relationship between the peak fourth-generation troponin T (TnT) measurement in the first 3 days after noncardiac surgery and 30-day mortality. Design, Setting, and Participants A prospective, international cohort study that enrolled patients from August 6, 2007, to January 11, 2011. Eligible patients were aged 45 years and older and required at least an overnight hospital admission after having noncardiac surgery. Main Outcome Measures Patients' TnT levels were measured 6 to 12 hours after surgery and on days 1, 2, and 3 after surgery. We undertook Cox regression analysis in which the dependent variable was mortality until 30 days after surgery, and the independent variables included 24 preoperative variables. We repeated this analysis, adding the peak TnT measurement during the first 3 postoperative days as an independent variable and used a minimum P value approach to determine if there were TnT thresholds that independently altered patients' risk of death. Results A total of 15 133 patients were included in this study. The 30-day mortality rate was 1.9% (95% CI, 1.7%-2.1%). Multivariable analysis demonstrated that peak TnT values of at least 0.02 ng/mL, occurring in 11.6% of patients, were associated with higher 30-day mortality compared with the reference group (peak TnT

Background: To evaluate the correlation and agreement between central venous saturation (ScvO2) and mixed venous saturation (SvO2) during cardiopulmonary bypass. Methods: Twenty-two consecutive patients scheduled for coronary artery surgery were prospectively included. Paired measurements of ScvO2 and SvO2 were performed 5 minutes after aortic cross-clamping, after each cardioplegia dose and after de-clamping of the aortic cross-clamp. ScvO2 and SvO2 were measured, respectively, by a fibreoptic catheter in the superior vena cava and on blood samples from the venous return line of the extracorporeal circuit, using a blood gas analyser Results: Ninety-five paired measurements of venous saturation were obtained. Correlation between the measurements was associated with an r = 0.55. The mean bias was 2.2 [Limits of agreement: –13.6%, +18%]. Changes in oxygen saturation over time showed an r = 0.4 and a mean bias of 0.2 [Limits of agreement: –17.9%, +18.3%]. Multivariate analysis identified the oxygen consumption index as the only factor explaining this variability. Conclusions: Although mean biases between the measurements were low, limits of agreement were too large to provide a clinically acceptable estimation of SvO2 by ScvO2 in these conditions. Variations in regional oxygen consumption seem to be the main factor worsening the relationship.

Introduction Dans les mois suivant une intervention chirurgicale pour fracture de l’extremite superieure du femur (FESF), le risque de deces chez les patients âges augmente d’un facteur x5 a x8. Nous avons teste l’hypothese qu’une prise en charge geriatrique peri-operatoire precoce, centree sur les comorbidites, ameliorait le pronostic a long terme. Patients et methodes Dans une etude de cohorte sur une periode de 6 ans, nous avons compare les patients âges de plus de 70 ans avec une FESF admis en orthopedie versus en unite peri-operatoire geriatrique (UPOG). Admissions faites de maniere chronologique avant/apres l’ouverture de l’UPOG. Les comorbidites etaient evaluees par l’echelle Cumulative Illness Rating Scale (CIRS). Le critere principal etait la mortalite a 6 mois. Dans un second temps, chaque cohorte etait comparee a une cohorte extraite des donnees de la base PMSI (n = 51 275) pour valider les resultats observes (appariement 3 :1, ajuste sur l’âge, le sexe et le CIRS). Resultats Nous avons inclus 131 patients dans la cohorte orthopedique et 203 dans la cohorte geriatrique. Les co-morbidites etaient plus frequentes dans la cohorte geriatrique (CIRS median : 8 vs 5 ; p = 0,001). Dans la cohorte geriatrique, la proportion de patients sans aucune reprise de la marche avait diminue (6 % versus 22 % ; p = 0,001). A 6 mois, les re-admissions (14 % versus 29 %, p = 0,007) et la mortalite (15 % versus 24 %, p = 0,04) etaient moins frequentes dans la cohorte geriatrique. Prenant en compte les comorbidites, le Risk Ratio de deces a 6 mois etait diminue (0,43, 95 % CI 0,25 a 0,73, p = 0,002). En comparaison avec les patients de la cohorte PMSI, la prise en charge en filiere geriatrique etait associee a une reduction de la mortalite intra-hospitaliere (p = 0,006). Conclusion Une admission precoce dans une UPOG dediee ameliore la mortalite a 6 mois et la morbidite des patients âges admis pour une FESF.

Resume Cette observation rapporte l'evolution clinique d'une pseudo-occlusion colique aigue idiopathique survenue en milieu de reanimation chez une femme de 68 ans, ventilee artificiellement. Deux colonoscopies avec exsufflation, pratiquees pour une dilatation c˦cale superieure a 10 cm, sont suivies de recidives precoces. L'administration de cisapride par voie orale permet la reprise d'un transit intestinal en 48 h sans complications. Le cisapride est une molecule gastro-enterokinetique qui stimule la motricite colique. Plusieurs cas de syndrome d'Ogilvie, dont l'evolution favorable semble liee a ce medicament, ont ete rapportes. La seule solution en cas d'echec des colonoscopies exsufflatives etant la c˦costomie, les auteurs proposent qu'une evaluation controlee du cisapride dans les pseudo-occlusions coliques aigues soit envisagee.

Reports about anaphylactic and anaphylactoid reactions to rocuronium have increased recently. We report two new cases of documented grade III anaphylaxis, leading to death in one patient. The first case occurred in an 81-year-old ASA II woman scheduled for emergency abdominal surgery. Severe hypotension and tachycardia were observed after rocuronium, without bronchospasm. Neosynephrine allowed rapid resuscitation, and the patient recovered fully. The second patient was a 64-year-old ASA II man scheduled for abdominal surgery. Severe haemodynamic instability and bronchospasm occurred after rocuronium. Despite immediate life support, the postoperative period was complicated by persistent low systolic pressure, acute respiratory distress syndrome, acute renal failure, disseminated intravascular coagulation and pancreatitis, leading to the death of the patient.

Introduction Les alterations de la fonction renale faisant suite a une chirurgie de l’aorte abdominale avec un clampage aortique sus renal sont frequentes et ont un impact majeur sur la mortalite postoperatoire. Plusieurs etudes suggerent un effet protecteur des statines sur la fonction renale postoperatoire [1] , [2] . Le but de notre etude est d’evaluer l’impact de la prise au long cours de statines a fortes doses sur la fonction renale apres cette chirurgie. Materiel et methodes Tous les patients beneficiant d’une chirurgie de l’aorte abdominale avec clampage sus renal entre le 1er janvier 2011 et le 31 decembre 2013 ont ete inclus. Ces patients sont divises en deux groupes : groupe 1 = statines forte dose (Atorvastatine 40–80 mg, Rosuvastatine 10–20 mg) ; groupe 2 = statine faible dose ou pas de statine. Un score de propension a ete construit avec tous les parametres susceptibles d’etre associe d’une part a la prise de forte dose de statines, et d’autre part a une insuffisance renale postoperatoire : bloqueurs du systeme renine-angiotensive (BSRA), creatinine preoperatoire, temps de clampage, pertes sanguines estimees (PSE), âge, facteur de Lee, insuffisance cardiaque, insuffisance coronaire clinique, diabete. L’association entre la prise de statine a forte dose et l’evolution de la clairance de la creatinine entre la periode preoperatoire et postoperatoire a ete estimee sur une population appariee (methode du voisin le plus proche). Resultats Le Tableau 1 reprend les caracteristiques cliniques et biologiques preoperatoires des 148 operes inclus. La prise de BSRA etait plus frequente chez les patients traites par statines forte dose. Apres appariement sur la valeur du score de propension, les caracteristiques des patients etaient equilibrees (deviation standardise maximum = 12 %). Dans la population appariee (114 patients), le groupe traite avec des fortes doses presentait une alteration de la clairance de la creatinine moins importante que les patients recevant des statines a faibles doses (−50,1 % ; p = 0,032). Aucune difference n’etait observee sur le recours a une dialyse postoperatoire (temporaire ou definitive). Discussion Chez les operes, l’utilisation de statines a forte dose au long cours est associee a une moindre alteration de la fonction renale en postoperatoire. La frequence, la diversite des mecanismes impliques dans l’insuffisance renale faisant suite a ce type de chirurgie (emboles de cholesterol, ischemie, thrombose…), l’absence de strategie preventive efficace et les consequences medico-economique de ces complications representent un probleme de sante publique. L’effet traitement suggere par cette etude devra etre confirme par une etude prospective a plus large echelle.

Introduction La lesion myocardique aigue postoperatoire ou Myocardial Injury after Noncardiac Surgery (MINS) [1] est definie par une elevation isolee de troponine en postoperatoire de chirurgie non cardiaque. Les dosages de troponine T UltraSensible de 5eme generation (TNTus), permettent une mesure plus precise de la troponine, tout en maintenant une excellente specificite pour l’origine cardiaque de la lesion (sans prejuger du mecanisme). L’objectif de cette etude est de determiner si un dosage de troponine TNTus preoperatoire (preTNTus) ameliore la stratification du risque de MINS, et, le cas echeant, de definir des valeurs seuils conditionnant le risque postoperatoire. Materiel et methodes Tous les patients operes en chirurgie vasculaire de septembre 2013 a mars 2014 ont ete inclus. Les caracteristiques cliniques et les dosages biologiques etaient colliges. Le critere de jugement principal etait le MINS selon la definition internationale. Les performances des preTNTus pour stratifier le risque de MINS etaient d’abord analysees avec des courbes ROC reechantillonnees sans prendre en compte les covariables. La zone d’incertitude decisionnelle etait determinee. L’apport de la preTNTus etait ensuite determine en prenant en compte les facteurs predictifs de MINS. L’apport predictif de la preTNTus etait alors estime a l’aide de la difference d’aire sous la courbe et du net reclassification index (NRI). Resultats Trois cent cinquante-six operes consecutifs ont etes etudies (96 chirurgies aortiques abdominales, 99 pontages distaux, 113 endarteriectomies carotidiennes, 21 anevrysmes femoro-poplites, 14 procedures endovasculaires, 8 amputations et 5 fistules arterio-veineuses). L’incidence des comorbidites etaient : HTA (49 %), cardiopathie ischemique (33 %), tabagisme actif (52 %), antecedent de pathologie cerebro-vasculaire (15 %), diabete (27 %), hypercholesterolemie (71 %), obesite (16 %), insuffisance renale chronique moderee (32 %) ; 76 % des operes etaient traites par antiagregants plaquettaires et 63 % par statine. L’incidence des MINS etait de 18,6 % [IC95 % : 14,9 %–23,0 %]. L’aire sous la courbe ROC etait de 0,84. La distribution des seuils optimaux est presentee sur la Figure 1 . Toute valeur superieure a 14 ng/L (borne inferieure de la zone d’incertitude decisionnelle) etait ensuite consideree comme anormale. Cent dix-sept (33 %) patients presentaient une preTNTus superieure a 14 ng/L. Parmi eux, 48 % presentaient un MINS, lorsque seulement 4,2 % des patients avec une preTNTus inferieure a 14 ng/L presentaient un MINS (p Discussion Cette etude demontre de l’interet de la preTNTus pour stratifier les operes avant une chirurgie vasculaire. Ainsi, une preTNTus permet d’identifier parmi des patients asymptomatiques programmes pour une chirurgie, des sujets ayant pres d’une chance sur deux de presenter un MINS.

Background and Goal of Study: General anesthesia (GA) during carotid endarterectomy (CEA) requires a tight hemodynamic control in order to limit neurological and cardiovascular complications. This study aimed to demonstrate that the hemodynamic stability is bet ter respected with Xenon than with sevoflurane during CEA under GA in old patients. Materials and Methods: This randomized controlled trial was approved by our local ethic commit tee (CPP ParisVI). Patients older than 65 years scheduled for CEA were included. Anesthesia was induced in both groups with propofol and remifentanil and a non-depolarizing neuromuscular blocking agents (atracurium) was used for tracheal intubation. For the maintenance phase, patients were randomly allocated to either Xenon (60%) or Sevoflurane (1.7%). 30% of oxygen was used for all patients. Both groups received remifentanil targeted concentration of 2 ng/ml and adapted according to clinical needs and spontaneous EEG (BIS) monitoring. Continuous recording of arterial blood pressure (ABP), airway pressure and electrocardiogram was done (Biopac(tm)). Tachycardia, bradycardia, hyper and hypotension were defined as a change of more than 40% compared to the basal state recorded at rest before induction. Intraoperative hemodynamic variability was calculated using sequential analysis of one minute provided by the continuous recordings of ABP. Af ter integration over the time, hemodynamic variability was expressed as a continuous variable in %.min. Fisher exact test and non parametric Wilcoxon test were used to compare these endpoints. Results and Discussion: 46 old patients (mean age was 75 +/7) were included in the two groups.

Background and Objectives Postoperative acute cardiac events are one of the most common causes of mortality following vascular surgery. The repercussions of myocardial infarction (MI) exacerbate immediate postoperative mortality and seriously impact on life expectancy. Postoperative surveillance to detect elevated troponin I (cTnI) levels (the most accurate cardiac biomarker for postoperative MI) is not only crucial to early diagnosis of postoperative MI but can also help limit long-term mortality by prompting appropriate treatment. However, the impact of such treatment on short- and long-term postoperative morbidity and mortality has not been studied. Management might be suboptimal. Our objective was to analyse the immediate and longer term (1 year) impact of following recommendations based on evidence-based data by intensifying treatment of coronary artery disease in patients presenting elevated postoperative cardiac cTnI levels following major vascular surgery. Programme We undertook a retrospective case-controlled study on a population of 665 consecutive patients who had undergone vascular surgery. The case subjects were the 66 patients (9.9%) with elevated postoperative cTnI. For each case, we selected 2 controls from the remaining patients using logistic regression and nearest neighbour matching methods applied to preoperative and intra-operative sets of variables Results According to an independent expert committee, 44 (67%) of the 66 patients had received treatment intensification. Mean follow-up was 14 months (range, 6–31). Intensified postoperative cardiovascular treatment was associated with significant benefit in terms of 1-year mortality (p=0.027) on comparing patients who had or had not received intensified treatment. There was no difference in mortality between patients receiving intensified postoperative therapy and those who did not experience a postoperative elevation in cTn1, suggesting that treatment might normalise life expectancy in patients with elevated cTnI. In over 70% of patients, the treatment taken at 1 year on a regular basis was no different from the treatment they had been given on discharge from hospital. Discussion and Conclusion In patients with elevated postoperative cTnI, short- and long-term outcomes can be improved by following evidence-based recommendations for the management of acute coronary syndromes. In addition, appropriate secondary prevention of coronary artery disease following hospital discharge contributes towards a positive impact on life expectancy in these patients. Contexte et objectifs L9insuffisance coronaire aigue reste l9une des principales causes de morbidite et de mortalite chez les operes de chirurgie vasculaire. Cette complication aggrave le risque postoperatoire immediat et altere de facon importante l9esperance de vie a moyen terme des operes. La mise en evidence d9une elevation de troponine (TnI) post operatoire qui detecte avec fiabilite une insuffisance coronaire aigue post operatoire, permet d9instaure un traitement adapte qui permettra une reduction de la mortalite a long terme. Cette hypothese est etayee par le fait que la prise en charge de l9insuffisance coronaire aigue postoperatoire parait souvent inadaptee, car l9impact de la prise en charge moderne de l9insuffisance coronaire aigue sur la mortalite a court terme et l9esperance de vie des operes n9a jamais ete etudie. Dans cette etude nous evaluons l9impact a long terme de l9intensification d9un traitement anti-ischemique coronaire chez des patients ayant presente une elevation post-operatoire de TnI (le bio-marqueur cardiaque le plus fiable pour le diagnostic d9insuffisance coronaire aigue post-operatoire). Programme Une etude cas temoins a donc ete realisee chez 665 operes consecutifs de chirurgie aortique. Les 66 cas (10 %) identifies correspondaient aux patients ayant presentes une elevation postoperatoire de TnI durant la periode d9etude. Pour chaque cas 2 temoins etaient apparies sur un groupe de variables preoperatoire (age, sexe, antecedent d9IDM, diabete…) et sur un groupe de variable per-operatoire (Volume de saignement, duree de chirurgie…). L9analyse statistique reposee sur des regressions logistiques et sur un appariement au plus proche. Resultats Une difference significative etait observee sur la mortalite a 1 an des patients ayant beneficie d9une intensification du traitement a visee coronaire (p=0.027). De plus, on n9observait pas de difference entre les courbes de survie des patients ayant beneficier d9une intensification de leur traitement et ceux n9ayant pas presentes d9elevation postoperatoire de TnI, ceci suggerant que cette strategie therapeutique a permis de normaliser l9esperance de vie des patients ayant presentes une elevation de TnI postoperatoire. Finalement, le traitement retrouve a un an n9etait pas different du traitement de sortie d9hospitalisation dans plus de 70% des cas. Conclusion Chez les operes souffrant d9une insuffisance coronaire aigue postoperatoire mise en evidence par une elevation du taux de troponine, la mortalite postoperatoire et l9esperance de vie a un an sont ameliores de facon significative par une prise en charge medicale de l9insuffisance coronaire aigue conforme aux recommandations de la litterature. Une prevention secondaire adaptee de l9insuffisance coronaire apres la sortie du malade de l9hopital participe a l9amelioration de l9esperance de vie notee a un an chez ces operes.

29 autotransfusions were realised in severe cases of trauma (20% of a sample of 143 traumatic emergencies). The recovery of haemothorax blood as well as the peroperative collection by a Cell Saver allowed the retransfusion of 1989 +/- 1,838 ml (225-7070 ml) of autologous blood, amounting to 56% of the average blood loss. A total of 69% of the patients received homologous blood. Eight patients (where the haemorrhage amounted to 143% of the blood volume) showed some coagulation troubles. Autotransfusion assures the immediate availability of blood while reducing the immunological and viral transfusion risks. Therefore haemothorax autotransfusion should be used systematically. Peroperative recollection by a cell-separator works well but is technically more tedious.

The reduction of bleeding during surgery can be aimed at for two reasons: to facilitate the operation by providing a bloodless field and/or to avoid blood loss requiring compensation by transfusion. These aims can be reached by reducing blood pressure or by acting on blood-clotting. For inducing hypotension sodium nitroprussiate and isoflurane are mainly used. Complex and precise monitoring is required for patient safety. Two drugs have been used to diminish bleeding: desmopressin and aprotinin. With the latter an important reduction (40 to 50%) of the blood loss has been achieved.