Routine screening for HIV, hepatitis B virus and hepatitis C virus in individuals undergoing oral and maxillofacial surgery.

OBJECTIVES: Given the effectiveness of treatment of HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, there are considerable benefits associated with determining HIV/HBV/HCV status. We evaluated the feasibility and acceptability of systematic screening and subsequent care in an oral and maxillofacial surgery department. METHODS: The anaesthesiologists proposed screening for HIV, HBV and HCV to all individuals of unknown infection status undergoing surgery between 19 April 2016 and 19 April 2017. The endpoints were the rates of test offer, acceptance/refusal and new diagnoses. Seropositive individuals were referred to infectious disease specialists. Associations between age, sex or surgery type and test offer (eligible individuals) or acceptance/refusal (those offered testing) were investigated. RESULTS: Of the 1407 individuals attending the department, 1322 were eligible for inclusion in the study. Testing was proposed to 899 individuals [68%; 95% confidence interval (CI) 65-71%], 831 of whom accepted the offer (92.4%; 95% CI 90.5-94.1%). Results were obtained for 787 individuals (41 samples were uncollected and three were invalid). Age was the only factor associated with test offer in multivariable analysis [odds ratio (OR) 0.90; 95% CI 0.84-0.97, per additional 10 years], and no factor was associated with acceptance. Of the five, three and eight individuals testing positive for HIV, HBV and HCV, four, two and one patient, respectively, reported prior knowledge of seropositivity. The new diagnosis rate was 0.13% (95% CI 0-0.7%) for HIV and HBV, and 0.89% (95% CI 0.36-1.82%) for HCV [three positive polymerase chain reaction (PCR) tests]. All individuals newly diagnosed with HIV or HCV infection received specific antiviral treatment. CONCLUSIONS: Rates of screening offer and acceptance were high. Substantial screening resources are required to decrease the impact of the hidden epidemics of HIV, HBV and HCV infections.

[Perioperative analgesia in urology and potential influence of anesthesia on oncologic outcomes of surgery]. / Analgésie peropératoire en urologie et influence potentielle de l'anesthésie sur les résultats de la chirurgie carcinologique.

INTRODUCTION: The objective of the current article was to present a review concerning current concepts of perioperative analgesia in urology and to assess the potential influence of anesthesia on oncologic outcomes after surgery. PATIENTS AND METHODS: Data on general anesthesia and perioperative analgesia were explored on Medline using the following MeSH terms: anesthesia; analgesia; pain urology; cancer; morphine; nefopam; tramadol; ketamine; local anesthetics; non-steroid anti-inflammatory treatments; surgery; cancer. Publications were considered on the following criteria: methodology, relevance and date of publication. RESULTS: The concepts of acute and chronic pain after surgery are discussed, as well as prevention and treatment. Types of available pharmacological substances are listed and the possible routes of administration for these products. The concept of multimodal analgesia and preemptive analgesia are exposed and their role for the prevention of perioperative pain. Recent studies suggest a relationship between the modes of anesthesia and analgesia in cancer surgery, and recurrence of the disease after surgery. CONCLUSION: Current concepts of perioperative analgesia offer new perspectives to urologists in the management of pain. Current scientific literature advocates regional anesthesia, the fight against pain and stress, and decreased use of opioids. In addition, the use of a multimodal analgesia seems to be an option for an optimal oncologic management of urologic tumours.

[Prevention of complications of general anesthesia linked with laparoscopic access and with robot-assisted radical prostatectomy]. / Complications de l'anesthésie générale inhérentes à la voie laparoscopique et à la prostatectomie totale robot-assistée.

INTRODUCTION: The aim of our work was to present a review of technical features and complications of general anesthesia during robot-assisted laparoscopic radical prostatectomy (RALRP). MATERIALS AND METHODS: Data on RALRP and general anesthesia were explored on Medline using the following MeSH terms: radical prostatectomy; morbidity; anesthesia complications; laparoscopy; robotics; Trendeleburg. Publications were considered on the following criteria: methodology, relevance and date of publication. RESULTS: There was no data of level of evidence 1 available. The first RALRP was reported in 2000. Technological innovation brought by the robot with its 3-D vision, the acquisition of degrees of mobility and a more ergonomic position for the surgeon, have led to a growing interest from new teams in the western world. However, the RALRP generates constraints for the anesthesia team who need to incorporate the rules of laparoscopy and the patient's specific installation to guarantee maximum safety. There are inherent complications with the installation of the patient himself in the Trendelenburg position (ocular, neurological, hemodynamic, respiratory) and respiratory complications related to the specific procedure in gaseous atmosphere due to pneumoperitoneum. One of the criteria of the quality of publications in the field of surgery is related to the objective evaluation of complications by appropriate scale systems and the complications of general anesthesia must also be absolutely recorded. CONCLUSION: RALRP had deeply modified the anatomical landmarks of the surgical removal of prostate cancer. However, the perioperative environment has also been completely altered and the installation of RALRP in the daily routine of a service requires from the anesthesia team to adapt their behavior to this sophisticated surgical access.

Perioperative management of combined heart-liver transplantation in patients with cirrhosis, renal insufficiency, or pulmonary hypertension.

UNLABELLED: STATING THE MAIN PROBLEM: Only few reports have detailed perioperative management and outcome of combined heart and liver transplantation (CHLT), and none describe the long-term renal function. METHODS: Three patients presented clinical signs of cardiomyopathy with reduced ejection fraction and proven cirrhosis with evidence of portal hypertension. Two of them presented renal failure, and the other pulmonary hypertension. After cardiac transplantation and closure of the sternum, liver transplantation was performed using systematically venovenous double-limb (portal and caval) bypass. RESULTS: Mean cold ischemic time for heart and liver was 2 h 46 min and 12 h 47 min, respectively. Intraoperative hemodynamics remained grossly stable during surgery. Mean transfusions were 12 red blood cell packs. All three patients received anti-R-Il2 antibodies at post-operative day 1 and 4. Mean plasma creatinine concentration was 90 ± 8 µmol/L one yr post-CHLT, vs 160 ± 62 µmol/L pre-CHLT. All three patients are alive with functional grafts after a mean follow-up of 26 months (12-38). CONCLUSION: CHLT could be performed safely through two consecutive and independent usual procedures. Perioperative hemodynamic stability, minimal blood loss, and routine splanchnic decompression are probably major determinants of a favorable outcome and good long-term renal function.

[Comparison of three ventilatory modes during immediate postoperative transfer of cardiac surgical patients]. / Comparaison de trois modes ventilatoires au cours du transport postopératoire immédiat du patient opéré de chirurgie cardiaque.

OBJECTIVE: Compare three ventilatory strategies during the immediate postoperative transfer of cardiac surgical patient. STUDY DESIGN: Prospective, comparative and observational study. PATIENTS AND METHODS: After approval by our local ethical committee, 330 patients undergoing on-pump cardiac surgery were consecutively included. Patients suffering from chronic obstructive pulmonary disease, exhibiting intraoperative hypoxemia or requiring nitric oxide were excluded. The ventilatory mode was left at the discretion of the anesthesiologist and included: controlled mechanical ventilation (FiO(2)=1, N=124) or (FiO(2)=0.6, N=106), and manual ventilation using rebreathing bag (N=100). A blood gas analysis was performed immediately prior to connecting patient at ventilator at the arrival in ICU. RESULTS: The mean duration of transfer was 3.9+/-1.4 min. Invasive pressure monitoring was used in all patients. The pulse oxymetry and electrocardiogram were respectively used in 78% and 24% of patients. PaO(2) values less than 100 mmHg and those more than 300 mmHg were more frequently found in patients ventilated by rebreathing bag (42%) and mechanical ventilation FiO(2)1 (52%), respectively. No significant difference was found between groups regarding PaCO(2) values. CONCLUSION: When rebreathing bag is used for transfer in ICU, severe decrease in PaO(2) may be observed. In absence of intraoperative hypoxemia, a mechanical ventilation with FiO(2)0.6 seems to be the most suitable ventilatory strategy for such short immediate postoperative transfer.

Tei index to assess perioperative left ventricular systolic function in patients undergoing mitral valve repair.

BACKGROUND: Using echocardiography, perioperative assessment of systolic function by fractional area change (FAC) is questionable in patients suffering from mitral regurgitation (MR). Tei index, an index expressing global cardiac function, has been reported to be unchanged after mitral valve surgery. We tested the hypothesis where the Tei index could be useful in assessing the perioperative cardiac function in patients undergoing mitral valve repair (MVR). METHODS: Twenty-five patients were enrolled. Transoesophageal echocardiography was performed perioperatively before and after the correction of MR. We compared the impact of the MVR on the left ventricular FAC and the Tei index. FAC was calculated from the transgastric short-axis view and Tei index was determined from the four chambers and deep transgastric views. RESULTS: Two patients were excluded because of poor acoustic windows. FAC significantly decreased after MVR from 53 (9)% to 42 (10)% (P<0.001), while Tei index was unaffected [0.46 (0.16) vs 0.47 (0.17), NS]. A significant relationship was found between the preoperative Tei index and the postoperative FAC (R=-0.64, P<0.001). Moreover, a significant and clinically relevant relationship was determined between the predicted (using preoperative Tei index) and the measured postoperative FAC (R=0.64, P<0.001). CONCLUSIONS: FAC but not the Tei index is influenced by MVR. The preoperative determination of the Tei index allows predicting postoperative FAC and offers the opportunity to identify patients in whom a severe unsuspected systolic dysfunction could render difficult the weaning from cardiopulmonary bypass.

Safety of HES 130/0.4 (Voluven(R)) in patients with preoperative renal dysfunction undergoing abdominal aortic surgery: a prospective, randomized, controlled, parallel-group multicentre trial.

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

Drug-eluting stent thrombosis in patients undergoing non-cardiac surgery: is it always a problem?

BACKGROUND: 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. METHODS: 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 I > or =0.15 ng ml(-1)) and the rate of in-stent thrombosis were analysed. RESULTS: 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. CONCLUSIONS: 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.

Effect of a low-dose ketamine regimen on pain, mood, cognitive function and memory after major gynaecological surgery: a randomized, double-blind, placebo-controlled trial.

BACKGROUND AND OBJECTIVE: Major gynaecological abdominal surgery is associated with moderate to severe postoperative pain, hyperalgesia and the need for multimodal analgesia to reduce high morphine consumption. A low-dose ketamine regimen appears to prevent postoperative hyperalgesia. We examined the potential beneficial effect of ketamine on postoperative pain management and cognitive function. METHODS: Ninety patients were included in this double-blind, randomized, placebo-controlled study to test the efficacy and adverse effects of ketamine (as an intraoperative bolus of 0.15 mg kg-1, followed postoperatively by ketamine 0.5 mg per morphine 1 mg in a patient-controlled analgesia device). All patients received additionally ketoprofen. The main end-point was morphine consumption over the first 24 h. Secondary efficacy and safety end-points were morphine consumption during the titration period and during the patient-controlled analgesia period (48 h), the number of morphine-related adverse effects and the results of psychometric tests. RESULTS: Ketamine, in combination with morphine and ketoprofen, did not improve postoperative pain scales and did not reduce morphine consumption and the incidence of morphine-related adverse effects. Ketamine did not modify mood, cognitive and memory functioning. CONCLUSION: Adding a low dose of ketamine to an efficacious multimodal analgesic regimen did not improve analgesia after gynaecological surgery. Although this combination appears to be safe, the lack of benefit suggests that a low dose of ketamine should not be used for routine care.

Minimum alveolar concentration of halogenated volatile anaesthetics in left ventricular hypertrophy and congestive heart failure in rats.

BACKGROUND: Although many physiological and pathological conditions affect minimal alveolar concentration (MAC), there are no reliable data on the MAC for halogenated anaesthetics during left ventricular hypertrophy (LVH) and congestive heart failure (CHF). The aim of this experimental study was to determine the MAC values of halothane, isoflurane, and sevoflurane in rats, at early and later stages of cardiomyopathic hypertrophy. METHODS: LVH was induced by ascending aortic stenosis in 3-4-week-old rats. LVH and CHF in each animal were assessed weekly by echocardiography. MAC of halothane, isoflurane, and sevoflurane was determined using the tail-clamp technique in spontaneously breathing rats from each group. Response vs no-response data were analysed using logistic regression analysis. Data are medians (95% confidence interval). RESULTS: The MAC of halothane [1.30% (1.26-1.34)], isoflurane [1.52% (1.48-1.57)], and sevoflurane [2.93% (2.78-3.07)] in rats with LVH was not different from sham-operated rats [respectively, 1.23% (1.20-1.26), 1.52% (1.47-1.56), and 2.90% (2.79-3.00)]. Conversely, the MAC of halothane [1.44 (1.39-1.50)] and isoflurane [1.74 (1.69-1.78)], but not sevoflurane [2.99 (2.93-3.06)], was significantly increased in rats with CHF. CONCLUSIONS: MAC values for halothane, isoflurane, and sevoflurane were unchanged in rats with pressure-induced overload LVH. Conversely, the MAC for halothane and isoflurane, but not sevoflurane, was significantly increased in rats with CHF.

An evaluation of capnography monitoring during the apnoea test in brain-dead patients.

BACKGROUND AND OBJECTIVE: Diagnosis of brain death usually requires the absence of spontaneous respiratory movements during the apnoea test and an arterial carbon dioxide partial pressure above 60 mmHg. On the other hand, although capnography (end-tidal CO(2)) is currently monitored in intensive care unit patients, it has not been evaluated during the apnoea test in brain-dead patients. Therefore, the aim of this prospective study was first to investigate the usefulness of capnography monitoring, and secondly to evaluate the variation of the carbon dioxide partial pressure-end-tidal CO(2) gradient during the apnoea test in clinically brain-dead patients. METHODS: After local Ethics Committee approval, 60 clinically brain-dead patients were investigated. End-tidal CO(2) was continuously recorded before, during and after the apnoea test. Arterial blood gases were sampled immediately before and after the apnoea test for calculation of the carbon dioxide partial pressure-end-tidal CO(2) gradient. RESULTS: The apnoea test was clinically positive in 58 patients, whereas end-tidal CO(2) was equal to 0 during the apnoea. During the 20-min apnoea test, carbon dioxide partial pressure increased from 40 +/- 7 to 97 +/- 19 mmHg (P < 0.001) with a rate of 2.8 +/- 0.9 mmHg min(-1), end-tidal CO(2) increased from 31 +/- 6 to 68 +/- 17 mmHg (P < 0.001) and carbon dioxide partial pressure-end-tidal CO(2) gradient increased from 9 +/- 4 to 29 +/- 10 mmHg (P < 0.001). In two patients, the apnoea test was clinically negative because of the occurrence of spontaneous respiratory movements, whereas capnography showed contemporaneously significant increases in end-tidal CO(2). CONCLUSIONS: End-tidal CO(2) should be systematically monitored and recorded, at least for medico-legal considerations, during the apnoea test in brain-dead patients. The high variability in the carbon dioxide partial pressure-end-tidal CO(2) gradient increase precludes any extrapolation of the carbon dioxide partial pressure from the end-tidal CO(2) at the end of the apnoea test.

Effects of a loading dose of morphine before i.v. morphine titration for postoperative pain relief: a randomized, double-blind, placebo-control study.

BACKGROUND: I.V. morphine titration (MT) allows adjustment of the dose needed for pain relief in the post-anaesthesia care unit (PACU). However, MT has limitations such as a delay to achieve pain relief. We thus assessed the effect of a fixed intraoperative loading dose of morphine administered before titration. METHODS: One hundred patients who were undergoing major orthopaedic surgery were included in a double-blind, randomized study comparing a loading dose of morphine (0.15 mg kg(-1)) with placebo administered intraoperatively. MT was then administered in the PACU followed by patient-controlled analgesia (PCA) over 24 h. Data are expressed as mean (sd). RESULTS: The initial VAS [41 (36) vs 52 (35), NS] was not decreased in the morphine group. The VAS was lower in the morphine group in the PACU and PCA periods. The time to achieve effective pain relief was not decreased in the morphine group. The total dose of morphine administered in the PACU (including the loading dose) was significantly increased in the morphine group (+31% in mg kg(-1), P<0.05). Morphine requirements during the PCA period were not different between groups. The incidence of sedation was increased and a severe episode of ventilatory depression occurred in the morphine group. CONCLUSIONS: A loading dose of morphine administered at the end of surgery slightly decreased the VAS but did not reduce the time to pain relief or morphine consumption within the first 24 h. This slight improvement in analgesia was obtained at the expense of morphine-related adverse events.

Comparison of stroke volume (SV) and stroke volume respiratory variation (SVV) measured by the axillary artery pulse-contour method and by aortic Doppler echocardiography in patients undergoing aortic surgery.

BACKGROUND: The goal of the study was to compare stroke volume (SV) and respiratory stroke volume variation (SVV) measured by pulse-contour analysis and aortic Doppler. METHODS: These were measured by pulse-contour analysis and thermodilution (PiCCO) and by aortic pulsed wave Doppler with transoesophageal echocardiography in patients undergoing abdominal aortic surgery. Simultaneous measurements were done at different times of surgery. All data were recorded on PiCCOwin software and videotape and analysed off-line by a blinded investigator. RESULTS: A total of 114 measurements were achieved in 20 patients. There was a good correlation and small bias between the PiCCO and the echo-Doppler values of the mean SV [r=0.885; bias=0.2 (8) ml], and between the minimum [r=0.842; bias=1 (9) ml] and maximum SV [r=0.840; bias=2 (10) ml] values. CONCLUSIONS: There is a fair correlation between pulse-contour analysis and aortic Doppler for beat-by-beat measurement of SV but not for calculation of SV respiratory ventilation.

Low negative predictive value of dobutamine stress echocardiography before abdominal aortic surgery.

BACKGROUND: According to previous studies, a negative dobutamine stress echocardiography (DSE) test before major vascular surgery indicates that postoperative myocardial necrosis is very unlikely. We believe that the use of new cardiac troponin assays which can detect small amounts of myocardial necrosis results in a lower DSE negative predictive value for myocardial necrosis. METHODS: A total of 418 consecutive patients were screened using the ACC/AHA Guideline for Perioperative Cardiovascular Evaluation for Noncardiac Surgery before scheduled abdominal aortic surgery. Of these 143 met ACC/AHA criteria for non-invasive testing and underwent DSE. Patients with a negative DSE were deemed to be fit for surgery. A positive DSE led to a coronary angiogram. DSE was negative in 110 (77%) and positive in 33 (23%) patients. Myocardial necrosis was monitored up to the third postoperative day by daily cardiac troponin I (cTnI) measurement and a daily 12-lead ECG. RESULTS: Coronary angiography showed artery stenosis in 27 (84%) of 32 patients with a positive DSE. The negative predictive value of DSE for cTnI elevation was 92.7% (95% CI 86.2-96.8%). This was significantly lower than the lowest value of negative predictive value for myocardial necrosis assessed in previous studies. CONCLUSION: A negative DSE prescribed before scheduled aortic surgery according to ACC/AHA guidelines does not rule out postoperative myocardial necrosis.

Postoperative myocardial infarction: pathophysiology, new diagnostic criteria, prevention.

With the introduction of biomarkers like troponin I (cTnI), our ability to identify and quantify myocardial infarction in the postoperative period has been greatly enhanced. Even small elevations of cTnI should be considered as a myocardial infarction. Small increases in cTnI postoperatively have indeed been found to be associated with worse short and long-term outcomes, the higher the cTnI level the worse the outcome. Studies undertaken in the 1980s when postoperative myocardial infarction (PMI) was detected by means of electrocardiogram recordings every 12 hours following operation suggested that this complication occurred on the second or third postoperative day. More recent studies where postoperative myocardial necrosis has been detected by repeated troponin dosages have revealed that, in fact, postoperative myocardial infarction appears much earlier between 12 and 32 hour after the end of surgery. Two types of PMI were identified based on intense troponin surveillance. They stem from two different major pathophysiological mechanisms. One seems to be related to plaque-vulnerability, while the other may be due to the effects of prolonged ischemia. The postoperative period should be regarded as a vulnerable period' that acts synergistically with both plaque and patient vulnerabilities in the development of PMI. Monitoring troponin levels in the postoperative period following surgery enables the identification of patients with myocardial damage and the institution of early aggressive intervention (e.g., intensive beta blockers therapy, adequate analgesia, correction of anemia) in order to prevent the evolution of PMI during this golden period' that lasts about two days. In patients that are prone to develop PMI, and especially in those who are prone to develop PMI related to plaque rupture, prevention can be achieved by better preoperative identification of the vulnerable plaque, and by a better plaque stabilization, either metabolically (e.g., statins) or by actual coronary stenting. Further understanding of the mechanisms underlying PMI, as well as their early identification, may contribute to the reduction of the incidence of PMI and its associated morality in the future.