Anesthetic drugs modulate feeding behavior and hypothalamic expression of the POMC polypeptide precursor and the NPY neuropeptide.

BACKGROUND: Several hypnotic drugs have been previously identified as modulators of food intake, but exact mechanisms remain unknown. Feeding behavior implicates several neuronal populations in the hypothalamic arcuate nucleus including orexigenic neuropeptide Y and anorexigenic pro-opiomelanocortin producing neurons. The aim of this study was to investigate in mice the impact of different hypnotic drugs on food consumption and neuropeptide Y or pro-opiomelanocortine mRNA expression level in the hypothalamic arcuate nucleus. METHODS: Saline control, isoflurane, thiopental, midazolam or propofol were administered to C57Bl/6 mice. Feeding behavior was evaluated during 6 h. In situ hybridization of neuropeptide Y and pro-opiomelanocortine mRNAs in the hypothalamus brain region was also performed. Data were analyzed by Kruskal Wallis test and analysis of variance (p < 0.05). RESULTS: Midazolam, thiopental and propofol induced feeding behavior. Midazolam and thiopental increased neuropeptide Y mRNA level (respectively by 106 and 125%, p < 0.001) compared with control. Propofol and midazolam decreased pro-opiomelanocortine mRNA level by 31% (p < 0,01) compared with control. Isoflurane increased pro-opiomelanocortine mRNA level by 40% compared with control. CONCLUSION: In our murine model, most hypnotics induced food consumption. The hypnotic-induced regulation of neuropeptide Y and pro-opiomelanocortine hypothalamic peptides is associated with this finding. Our data suggest that administration of some hypnotic drugs may affect hypothalamic peptide precursor and neuropeptide expression and concomittantly modulate food intake. Thus, this questions the choice of anesthetics for better care management of patients undergoing major surgery or at risk of undernutrition.

Residents in tutored practice exchange groups have better medical reasoning as measured by script concordance test: a controlled, nonrandomized study.

STUDY OBJECTIVE: Clinical reasoning by anesthesiology residents in emergency situations where optimal management is uncertain could be improved by setting up a tutored practice exchange group. This study attempted to evaluate the impact of a practice exchange group (PEG), tutored by a senior anesthesiologist, on anesthesiology residents in emergency situations. Changes in clinical reasoning were measured by script concordance tests (SCT). DESIGN: We conducted a controlled, non-randomized study. SETTING AND PARTICIPANTS: Participants are residents in anesthesiology in Rouen, Caen and Amiens University Hospitals. INTERVENTIONS: Two resident groups were made up without randomization. The first group was the control group and consisted of residents from Amiens University Hospital and Caen University Hospital. The second study group (PEG group) consisted of residents from Rouen University Hospital, who followed weekly PEG sessions. Two groups had the same learning objectives except the PEG. MEASUREMENTS: In both the control group and the study group, each resident's clinical reasoning was assessed in the same formal manner by SCT. The primary outcome measurement of this study was to compare SCT results in the study group with PEG training (PEG group) with those without (control group). MAIN RESULTS: Performance in the SCT, expressed as degree of concordance with the expert panel (95% CI), was better in the PEG group (64% [62.1%-66%]) than in control group (60% [57.5%-62.8%])) (P= .004). CONCLUSION: Our study strongly suggests that an expert-directed, peer-conducted educational training program may improve the clinical reasoning of anesthesiology residents as measured by SCT.

[Interaction between hypnotic agents and the hypothalamic-pituitary-adrenocorticotropic axis during surgery]. / Modulation de l'axe hypothalamo-hypophyso-surrénalien par l'utilisation des agents hypnotiques dans le contexte chirurgical.

During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.

Remote cerebellar hemorrhage as an early and potentially lethal complication of a discal lumbar herniation surgery.

Remote cerebellar hemorrhage (RCH) is an infrequent but serious complication after lumbar herniation surgery. Little is known about this complication but excessive cerebrospinal fluid (CSF) leakage is thought to be a leading cause of RCH. We describe the case of a patient suffering from a life-threatening RCH, which occurred a few hours after lumbar disc herniation surgery.

Incidence of anaerobic bacteria in patients with suspected pneumonia in surgical Intensive Care Unit.

BACKGROUND: Few studies have investigated the incidence of pulmonary anaerobes in a specific population in surgical Intensive Care Unit (ICU). The objective of this work was to determine the incidence of anaerobes in surgical ICU patients with suspected pneumonia. METHODS: This was a prospective observational, single-center study. Analysis was based on data collected over 30 months from the surgical ICU of a tertiary care hospital (Rouen University Hospital), including data on risk factors for anaerobes in the lungs. Patients with suspected pneumonia (community-acquired or nosocomial) were included. Bacteriological sampling was performed by protected distal bronchial sampling (PDBS) with minilavage under bronchoscopy. Aerobic and anaerobic cultures were performed for each sample. Clinicians were only aware of aerobic results. Univariate and multivariate statistical analysis compared groups with and without anaerobes. RESULTS: A total of 134 samples were obtained from 117 patients. Surgery was performed on 74 patients (63.2%), within 24 hours of admission. Fifty-four patients (46.2%) had a chest trauma and 20 patients (17.1%) were admitted for a digestive pathology. Average age was 53.6±20.9 years and sex ratio was 5.9 (100 men/17 women). Average SAPS II was 41.6±15.1, median length of ICU stay was 23 days (25th percentile=13, 75th percentile=33), and median duration of mechanical ventilation was 21 days (25th percentile=11, 75th percentile=28). Mortality rate in ICU was 14.5%. After sampling, diagnosis of pneumonia was confirmed in 70 cases (52.2%). Anaerobe cultures were positive in 11 samples taken from 11 different patients (overall incidence 8.2%). Aerobic bacteria were also involved in 9 patients (81.8%). In univariate analysis, enteral feeding (P=0.02) and absence of catecholamines at time of sampling (P=0.003) were significantly associated with the presence of anaerobes in PDBS. Enteral nutrition was also found to be a risk factor in multivariate analysis (OR=11.8, 95% CI [1.36 to 102.4] P=0.025). Prior antianaerobic antibiotic treatment was not a protective factor. No difference was observed regarding the notion of aspiration, survival, total length of stay and duration of mechanical ventilation, or evolution of pneumonia between the two groups. CONCLUSION: Our study demonstrates the presence of anaerobic bacteria in the lung samples of patients from surgical ICU with an incidence comparable to that found in populations from medical ICU departments. Anaerobic morbidity in our study is in line with recent literature.

[Extracorporeal membrane oxygenation support for tako-tsubo syndrome after urgent caesarean section]. / Assistance par extracorporeal membrane oxygenation au cours d'un syndrome de tako-tsubo après césarienne en urgence.

Tako-tsubo syndrome is a rare cardiomyopathy secondary to catecholamine toxicity responsible of myocardial stunning. Severe complications such as cardiogenic shock or ventricular arrhythmia can occur. We presented the case of a 32-year-old woman victim of a tako-tsubo syndrome with severe cardiogenic shock during surgical procedure for urgent caesarean section. After refractory haemodynamic failure, the patient benefits from extracorporeal membrane oxygenation support device with success.

[Magnesium sulfate in the prophylaxis of eclampsia: a retrospective study]. / Évaluation de l'utilisation du sulfate de magnésium dans la prévention secondaire de l'éclampsie: étude rétrospective sur 39 cas.

INTRODUCTION: The use of magnesium sulfate (MgSO(4)) has been advocated since 2000 in France in the management of eclampsia. The aim of this study was to determine the frequency of use of this treatment for eclampsia in a French department. PATIENTS AND METHODS: All patients obstetrical patients admitted to Critical Care Units of Seine-Maritime for eclampsia over a period of 7 years (2002-2008) were included. Obstetric data, the treatment used for eclampsia and pre-eclampsia and maternofetal complications were collected. The primary outcome parameter was the use of MgSO(4) in the secondary prevention of eclampsia. RESULTS: Thirty-nine patients were included. Nineteen patients (48%) had eclampsia in prepartum, three (8%) in per-partum and 17 (44%) in post-partum periods. The use of MgSO(4) in the secondary prevention of eclampsia was observed in 92% of cases (36/39). Primary prevention was seen in 8% of cases. The duration of treatment was 2 days (1-7 days). The maternal and perinatal mortality was respectively 2.5 and 11%. CONCLUSION: In this study, the use of MgSO(4) in the secondary prevention is frequent. This result emphasizes the importance of the recommendations of learned societies in the homogenization of the management of rare but serious conditions such as eclampsia.

[Hypothermia at admission increases the risk of pulmonary contusion's infection in intubated trauma patients]. / L'hypothermie à l'admission augmente le risque d'infection des contusions pulmonaires chez les patients polytraumatisés sous ventilation invasive.

OBJECTIVES: Pulmonary contusion (PC) is common in cases of polytrauma. The aim of this study was to perform a multivariate analysis of risk factors associated with the occurrence of infection in PC and analyze the microbiological epidemiology. PATIENTS AND METHODS: All patients with PC admitted to the intensive care unit (ICU) between January 2002 and December 2006 were included in this retrospective observational study. Patients with penetrating thoracic trauma or those who died in the 48hours following admission to hospital were excluded. Diagnosis of bacterial infection in PC was performed if hyperthermia was associated with a positive quantitative culture (103 colony forming units/mL) on the bronchial sample. Univariate analysis provided statistical difference between variables that were integrated in the multivariate analysis model. Multivariate analysis was then performed to determine the risk factors of bacterial infection in PC. RESULTS: One hundred and seventeen patients were included. The incidence of bacterial infection in PC was 33.3% (39 patients). The most frequently encountered bacteria were Haemophilus sp., Staphylococcus aureus, Enterobacteriaceae, Pseudomonas sp. and Streptococcus sp. According to multivariate analysis, the existence of hypothermia at hospital admission increased the risk of PC infection (OR=2.61; IC 95% [4.2-13.3]). CONCLUSION: In conclusion, PC was infected in 33.3% of cases. The existence of hypothermia was identified as a risk factor. A prospective study is warranted to confirm these results.

[Evaluation of the concordance between guidelines and transfusion practices in neonatal intensive care units]. / Évaluation de la concordance entre recommandations et pratiques transfusionnelles en unités de soins intensifs néonataux.

OBJECTIVE: To assess the concordance rate between the prescriptions of blood products and Afssaps guidelines for transfusion practices in neonatology. STUDY DESIGN: Retrospective monocentric study. PATIENTS AND METHODS: Children transfused in the neonatology intensive care units in the Universitary Hospital of Rouen were included. Concordance rates between transfusion prescriptions, delivered and transfused products and the Afssaps guidelines were assessed. Any additional costs resulting from a theoretical discordance was also assessed. RESULTS: In 2006, 380 PSL were administered to 168 newborn children (NBC). Packed red blood cells (PRBC) represented the most often transfused products (n=290, 76%). Fifty packed platelets (PP) were transfused (13% of the blood products) and 41 fresh frozen plasmas (11%). Overall concordance rate between the Afssaps guidelines and the prescriptions was 64.9%. In 35.1% of cases, the prescription was excessive, compared to the recommendations. Excessive transfusion represented a total of 27,307 euros. CONCLUSION: Global concordance's rate between the guidelines and the prescriptions is fairly well. PRBC are the most blood product transfused. Excessive transfusions related to this concordance rate are leading to important theoretical costs. New informations to the guidelines are warranted to improve transfusional practices in this institution.

[Conditions of decision making of admission or non-admission in surgical intensive care unit]. / Conditions de prise de décision d'admission ou de non admission en réanimation chirurgicale.

OBJECTIVES: To describe the condition of the decision-making of admission and non-admission in intensive care unit. STUDY DESIGN: Non-interventional observational cohort. PATIENTS AND METHODS: Retrospective analysis of declarative terms of decision-making of patients admitted or denied in a surgical intensive care unit. The decision-making in the two admitted or not admitted troops was compared. RESULTS: That it is during a non-admission (149 decisions) or of an admission (149 decisions), the decision-making process was not very different. The instruction of the files was regarded as collegial in nearly 80% of the cases by the intensivist in load. The dialogue precedent the decision utilized generally several speakers but who could be residents. The participation of the patient and/or his close relations, as that of the ancillary medical personnel was rare. No person of confidence or anticipated directive was quoted. More than 50% of the decisions were taken within a time lower than 30 minutes. The decisions of non-admission were considered to be more difficult than the decisions of admission. Traceability was not automatically given. CONCLUSION: Thus, this study shows that in its current form the intensivists of the service estimate that in the majority of the cases the instruction of the files was collegial. However, the conditions of seniorisation of the decision, the collection of opinion of the patient and/or his close relations and the traceability are tracks of improvement to be implemented in certain circumstances of admission or non-admission.

[Reliability of pulsatile saturometry in patients with shock. Digital standard sensors are not reliable for facial measurement!]. / Fiabilité de la saturométrie pulsée chez les patients en état de choc. Les capteurs digitaux standard ne sont pas fiables sur les sites faciaux !

INTRODUCTION: Non-invasive monitoring of oxygen saturation by pulse oxymetry (SpO(2)) is sometimes perturbed on fingers during shock states. Other sites are possible (toes, forehead, nose, ear). Self-adhesive standard digital sensors are commonly used off-label in these sites. We have assessed their reliability for all of these sites. METHODS: We have studied patients presenting a stabilized shock state and receiving vasoconstrictive catecholamines. When an arterial blood gas was ordered, six SpO(2) were measured quasi-simultaneously (self-adhesive standard sensors): right and left index, toe, forehead, nose and ear. SpO(2) at "finger", "toe", "forehead", "nose" and "ear" were compared to the arterial oxygen saturation (SaO(2)) by using the Bland and Altman method. The plethysmographic curve was assessed as "correct" or "unsatisfactory". RESULTS: Hundred and ten patients were included (63 ± 15 years, SAPSII 46 ± 16, catecholamines: 0.6 ± 0.5 µg/kg/min). Plethysmographic curves are more often of "correct" quality for fingers (90%) than for the other locations (50 to 70%). Bias are low for all the locations (-0.1 to +1.5%). Limits of agreement are around ±5% for fingers and toes, but as high as ±15% for the face locations. When the analysis is restricted to plethysmographic curves of "good" quality, the limits of agreement are unchanged for fingers and toes, but improved (between ±5 to ±10%) for face locations. CONCLUSION: In patients with a shock receiving vasoconstrictive catecholamines, the reliability of SpO(2) measurements with standard sensors appears better for fingers than for toes and face locations. These standard sensors should be discouraged for facial measurement because of their low reliability, even when the plethysmographic curve seems correct. Sensors specifically designed for each facial site exist, and their reliability should be estimated in patients receiving vasoconstrictive catecholamines.

[Dental trauma and anaesthesiology: epidemiology and insurance-related impact over 4 years in Rouen teaching hospital]. / Lésions dentaires et anesthésie : épidémiologie et impact assurantiel sur quatre années au CHU de Rouen.

OBJECTIVES: Dental injuries are the first cause of sinistrality in anaesthesiology. However, few insurance-related data are available concerning the publicly-owned establishments, in particular on the cost of the complaints deposited. We studied the epidemiology of dental trauma in a teaching hospital and brought it closer to the induced insurance-related costs. PATIENTS AND METHODS: We conducted a retrospective study, examining the files of declaration of dental trauma, from January 2005 to December 2008. The litigations for dental injuries treated by Quality and Services Department were also analysed. RESULTS: Seventy-two cases of dental lesions were declared, i.e. 1/1528 general anaesthesias. Concerning the risk factors of lesion, 47 patients (65%) presented bad dental conditions identified during the pre-anaesthetic consultation; 27 patients (37%) had criteria for difficult intubation listed on the sheet of anaesthesia. The association of the 2 factors was found among 20 patients. The indication of information to the patient on the dental risk was registered on the sheet of anaesthesia in 17% of cases. The Quality and Services Department recorded 23 complaints for dental trauma over the period. In 4 cases the complaint was followed by a compensation for an average amount equal to 608 (256-1002) Euros, i.e., a total cost of 2434 Euros. CONCLUSIONS: The two main risk factors of dental lesion are well identified with the consultation of anaesthesia and are noted on the file. However, information to the patient on this risk is seldom notified. The incidence of dental lesions is important, but few complaints open right to financial repair for a very low insurance-related total amount.

[Evaluation of the impact of prescription analgesic during the anaesthesia consultation on the incidence of postoperative pain at home in ambulatory orthopaedic surgery]. / Évaluation de l'impact d'une prescription d'antalgiques réalisée lors de la consultation d'anesthésie sur l'incidence de la douleur à domicile en chirurgie ambulatoire orthopédique.

INTRODUCTION: Postoperative pain at home in ambulatory surgery is a major problem. To improve its management, the French society of anaesthesia emphasizes the importance of writing prescriptions for analgesic during the preanaesthetic consultation. The objective of this study was to assess the impact of this prescription on the incidence of postoperative pain at home in ambulatory orthopaedic surgery. PATIENT AND METHODS: We conducted a prospective evaluation in the ambulatory surgery unit of Rouen University Hospital. We were able to identify two periods of 1 year with implementation of a systematic prescription of analgesics during the postoperative period (P1) or during the preanaesthetic consultation (P2). The evaluation of this measurement was made by a telephone survey conducted the day after surgery. The main parameter was the incidence of postoperative pain at home defined by the occurrence of a pain greater to 3/10 on a numerical scale (FR). Secondary parameters were demographic and anaesthetic data, the incidence of moderate pain (FR ≤ 3), treatment adherence and patient satisfaction. RESULTS: We included 638 patients and 531 were analysed: 28% of patients had an EN greater than 3 the day following surgery. There is no difference between the two periods (30% for P1 versus 27% for P2). The analysis of subgroups showed that in the general anaesthesia group, 30% of patients had an EN greater than 3 for P1 versus 18% for P2 (P<0.01). Furthermore, 55% of patients expressed moderate pain (FR ≤ 3) for P1 versus 22% for P2 (P<0.01). Moreover, 89% of patients reported having an adequate analgesic treatment. The overall observance was 64%, 53% for P1 versus 75% for P2 (P<0.01). DISCUSSION: The systematic prescription of analgesics during the preanaesthetic consultation does not decrease the intensity of moderate to severe pain. On the other hand, this procedure seems to be positive for the people who underwent a general anaesthesia.