[Predictive scores used during the anesthetic preoperative visit. Part 2. Assessment of perioperative risk]. / Scores prédictifs employés lors de la consultation d'anesthésie. Partie 2: évaluation des risques peropératoires.

Anesthesia remains a high-risk specialty, even though the discipline has evolved considerably over the last few decades. Independently of postoperative complications, some risks are inherent to the perioperative period itself. In this narrative review of the literature, we describe these risks and the predictive scores, allowing an assessment of these complications. All these scores are designed to detect high-risk patients and to promote personalized medicine and individualized anesthesia. They also increase the objectivity of the preoperative assessment. Finally, using these scores, the practitioner can more accurately respond to the patient who presents anxiety regarding the perioperative period.

L'anesthésie-réanimation reste une spécialité à risque, même si la discipline a fortement évolué au cours des dernières décennies. Indépendamment des complications postopératoires, il existe des risques inhérents à la période peropératoire en elle-même. Dans cette revue narrative de la littérature, nous décrivons quels sont ces risques et quels sont les scores prédictifs permettant d'appréhender au maximum ces complications. Tous ces scores ont pour finalité de dépister les patients à haut risque et de tendre vers une médecine personnalisée, une anesthésie individualisée. Ils augmentent également le caractère objectif de l'évaluation préopératoire. Finalement, ils offrent au praticien la possibilité de répondre plus précisément au patient qui présente une anxiété face à la période périopératoire.

[Treatment of post-total knee replacement gonalgy by radiofrequency ablation of the genicular nerves]. / Traitement de gonalgies post-remplacement prothétique total de genou par thermoablation des nerfs géniculés.

Neurotomy of genicular nerves by radiofrequency is a technique efficient to reduce mecanic knee pain and pain after total knee replacement. In this article, we describe the case of a patient that has suffered from chronic knee pain after total knee replacement. The patient has successfully benefited of a neurotomy of genicular nerves by radiofrequency in the inferior right limb.

La thermoablation par radiofréquence des nerfs géniculés est une technique permettant d'atténuer les gonalgies d'origine mécanique ainsi que celles persistant après remplacement prothétique total de genou. Dans cet article, nous rapportons le cas d'une patiente souffrant de gonalgies persistantes après remplacement prothétique total du genou droit qui a bénéficié avec succès d'une neurolyse par radiofréquence des nerfs géniculés (ou thermocoagulation des nerfs géniculés) du membre inférieur droit.

[Predictive scores used during the anesthetic preoperative visit. Part 1. Assessment of postoperative complications]. / Scores prédictifs employés lors de la consultation d'Anesthésie. Partie 1. Evaluation des complications postopératoires.

Anesthesia is changing, moving from an intraoperative medicine to a transversal perioperative medicine. The evolution of the preoperative anesthetic consultation is part of this evolution. Recently, anesthesiologists attempt to categorize their patients to detect as early as possible those at risk of short, medium, and long-term complications. In that way, a personalized (individualized) anesthesia could be performed considering the patient's comorbidities as well as the type of surgery. Respect for the guidelines is easier to achieve with such personalized medicine. For this purpose, anesthesiologists can use predictive scores. In the last few years, there was an increase in the availability of these validated scores. A shared feature of these scores is to provide objectivity but also efficiency in their ability to be predictive while being easy and quick to apply in clinical practice. Thereby, anesthesiologists can inform the patient with more accurate information concerning their perioperative risks. Finally, these scores are part of a public health care policy that aims to reduce expenses by optimizing patient management and preoperative testing. These scores provide a global vision of the patient, which can be shared and understandable by the different practitioners.

L'anesthésie-réanimation est en pleine mutation, évoluant d'une médecine peropératoire à une médecine transversale périopératoire. L'évolution de la consultation d'anesthésie préopératoire s'inscrit dans ce cadre. L'anesthésiste-réanimateur cherche ainsi à sérier les patients afin de dépister, le plus précocement, les patients à risque de complications à court comme à moyen et long termes. De la sorte, il est possible de pratiquer une anesthésie personnalisée, individualisée, indépendante de critères démographiques et prenant en compte les comorbidités spécifiques de chacun ainsi que le type de procédure envisagée. Pour ce faire, l'anesthésiste dispose de scores prédictifs validés dont le nombre tend à croître ces dernières années. Ces scores ont pour dénominateur commun d'apporter de l'objectivité, d'être performants et efficients dans leur caractère prédictif, tout en étant d'application aisée et rapide en pratique clinique courante. Ils permettent, en outre, à l'anesthésiste de fournir au patient une information plus éclairée quant aux risques encourus. Enfin, ils s'inscrivent dans une logique de réduction des coûts en santé publique, en permettant d'optimaliser la prise en charge des patients, de rationaliser la prescription d'examens complémentaires et en offrant une vision du patient pris dans sa globalité. Cette vision est lisible par les différentes lignes de soins.

[Interscalene block and shoulder surgery. Literature review and new method of infiltration]. / Bloc interscalénique et chirurgie de l'épaule. Revue de la littérature et nouvelle méthode d'infiltration.

Nowadays, interscalene block is the gold standard for intra- and post-operative analgesia for shoulder surgery. It consists of distributing a sufficient volume of local anesthetics, within the interscalenic space which contains the C5 to C7 nerve roots. Due to its proximity to the area where the anesthetic is injected, the phrenic nerve can be transiently blocked causing a kind of paralysis of an hemidiaphragm. First, the use of ultrasound has reduced the incidence of diaphragmatic hemiparesis especially when the injection is performed at the C7 level rather than the C5 or C6 level. Then, decreasing the doses of local anesthetics has reduced the diffusion to the non-targeted structures, such as the phrenic nerve, causing less diaphragmatic hemiparesis. Finally, Palhais and Lee et al discovered that injecting LA at distance from the nerves roots can be useful in reducing this side effect. Based on their work, we decided to inject the local anesthetic into the muscle fascia. Our experience with this injection into the muscle itself seems to confirm the results described in the literature with less diaphragmatic hemiparesis. Further studies are needed to support our hypothesis and will be the subject of future researches in our institution.

De nos jours, le bloc interscalénique est la technique de référence pour l'analgésie per- et postopératoire de la chirurgie d'épaule. Il consiste à distribuer un volume d'anesthésique local suffisant, au sein du défilé inter-scalénique qui contient les racines nerveuses C5 à C7. En raison de sa proximité de la zone où est injecté l'anesthésique, le nerf phrénique peut être transitoirement bloqué engendrant une sorte de paralysie d'un hémidiaphragme. En premier, l'utilisation de l'échographie a permis de réduire l'incidence de l'hémiparésie diaphragmatique, surtout quand l'injection est réalisée au niveau C7 plutôt qu'au niveau C5 ou C6. Ensuite, la réduction des doses d'anesthésiques a diminué la diffusion vers des structures, autres que celles ciblées, telles que le nerf phrénique, engendrant moins d'hémiparésie diaphragmatique. Enfin, dans la même perspective, l'intérêt d'une injection à distance du plexus retrouvé par Palhais et Lee et coll. a diminué aussi cet effet secondaire. Sur base de leurs travaux, nous avons décidé d'injecter l'anesthésique local dans le fascia du muscle. Notre expérience avec cette injection au sein même du muscle semble confirmer les résultats décrits dans la littérature, avec moins d'hémiparésie diaphragmatique. D'autres études sont nécessaires pour étayer notre hypothèse et feront l'objet de futures recherches dans notre institution.

Teaching humanitarian surgery: Filling the gap between NGO needs and subspecialized surgery through a novel inter-university certificate.

Background: Access to surgical care is a global health burden. A broad spectrum of surgical competences is required in the humanitarian context whereas current occidental surgical training is oriented towards subspecialties. We proposed to design a course addressing the specificities of surgery in the humanitarian setting and austere environment.Method: The novelty of the course lies in the implication of academic medical doctors alongside with surgeons working for humanitarian non-governmental organizations (NGO). The medical component of the National Defense participated regarding particular topics of war surgery. The course is aimed at trained surgeons and senior residents interested in participating to humanitarian missions.Results: The program includes theoretical teaching on surgical knowledge and skills applied to the austere context. The course also covers non-medical aspects of humanitarian action such as international humanitarian law, logistics, disaster management and psychological support. It comprises a large-scale mass casualty exercise and a practical skills lab on surgical techniques, ultrasonography and resuscitation. Attendance to the four teaching modules, ATLS certification and succeeding final examinations provide an interuniversity certificate.30 participants originating from 11 different countries joined the course. Various surgical backgrounds, training levels as well as humanitarian experience were represented.Feedback from the participants was solicited after each teaching module and remarks were applied to the following session. Overall participant evaluations of the first course session are presented.Conclusion: Teaching humanitarian surgery joining academic and field actors seems to allow filling the gap between high-income country surgical practice and the needs of the humanitarian context.

[Preoperative fasting : state of the art]. / Intérêt du jeûne préopératoire : mise au point.

Inhalation of gastric content is a significant risk factor for perioperative complications. Preoperative fasting reduces this risk. The preanesthesia fasting time is variable and is subject to recommendations from different scientific societies. The clinician can identify some risk factors for inhalation during the preoperative anesthetic consultation. On the day of the procedure, the gastric ultrasound allows quantitative or semi-quantitative assessment of the gastric content. In that way, the anesthesiologist can adapt the anesthesia, in particular by using a so-called rapid sequence induction and esophageal compression.

L'inhalation du contenu gastrique représente un important facteur de risque peropératoire. Le jeûne préopératoire permet de limiter ce risque. La durée du jeûne est variable selon les patients et les circonstances. Elle est soumise à des recommandations par différentes sociétés savantes. La consultation pré-anesthésique permet d'identifier certains facteurs de risque d'inhalation. Le jour de l'intervention, l'échographie de l'estomac permet de guider l'évaluation quantitative ou semi-quantitative du contenu gastrique. La stratégie anesthésique est ainsi adaptée à la balance bénéfice-risque, notamment en utilisant une induction dite «en séquence rapide¼ et une compression oesophagienne lors des interventions chirurgicales en urgence.

[Autonomic hyperreflexia after spinal cord injury : perioperative management]. / L'hyperréflexie autonome après lésion médullaire : prise en charge en période périopératoire.

Spinal cord injury can have widespread consequences beyond the disruption of sensory and motor functions. Injury at or above the sixth thoracic spinal cord segment frequently leads to dysregulation of the autonomic nervous system, which results in a syndrome called autonomic hyperreflexia or dysreflexia. It is a hypertensive crisis triggered by visceral or somatic stimuli below the level of the injury and caused by sympathetic spinal reflexes not modulated by regulatory centers in the brain. Patients with spinal cord injuries frequently undergo surgery for multiple reasons. Because of the potentially lethal complications of autonomic hyperreflexia, physicians, and in particular anaesthesiologists, must be aware of the underlying pathophysiological mechanisms and adequate perioperative management.

Les lésions de la moelle épinière peuvent avoir de nombreuses conséquences autres que la perturbation des fonctions sensitives et motrices. Une lésion d'un niveau médullaire supérieur ou égal au sixième segment thoracique (T6) entraîne, fréquemment, une dysrégulation du système nerveux autonome et le développement d'un syndrome appelé hyperréflexie ou dysréflexie autonome. Il s'agit d'une crise hypertensive déclenchée par des stimuli viscéraux ou somatiques sous le niveau de la lésion et causée par des réflexes sympathiques médullaires non modulés par les centres régulateurs encéphaliques. Les patients porteurs de lésions médullaires bénéficient, régulièrement, d'interventions chirurgicales pour des raisons multiples. Les complications potentiellement létales de l'hyperréflexie autonome exigent des médecins et, en particulier, des anesthésistes-réanimateurs une connaissance des mécanismes physiopathologiques sous-jacents et une prise en charge péri-interventionnelle adéquate.

The effect of force applied to the left paratracheal oesophagus on air entry into the gastric antrum during positive-pressure ventilation using a facemask.

Cricoid force is widely applied to decrease the risk of pulmonary aspiration and gastric antral insufflation of air during positive-pressure ventilation, yet its efficacy remains controversial. We compared manual oesophageal compression at the low left paratracheal and cricoid levels for the prevention of gastric antral air insufflation during positive-pressure ventilation by facemask in patients scheduled for elective surgery under general anaesthesia. After gaining written consent, participants were randomly allocated by sealed envelope to one of three groups: oesophageal compression by 30 N paratracheal force (paratracheal group); oesophageal compression by 30 N cricoid force (cricoid group); or no oesophageal compression (control group). Gastric insufflation of air was assessed before and after positive-pressure ventilation by ultrasound measurement of the antral cross-sectional area and/or presence of air artefacts in the antrum. The primary outcome measure was the proportion of participants with ultrasound evidence of gastric insufflation. We recruited 30 patients into each group. Before facemask ventilation, no air artefacts were visible in the antrum in any of the participants. After facemask ventilation of the participant's lungs, no air artefacts were seen in the paratracheal group, compared with six subjects in the cricoid group and eight subjects in the control group (p = 0.012). Our results suggest that oesophageal compression can be achieved by the application of manual force at the low left paratracheal level and that this is more effective than cricoid force in preventing air entry into the gastric antrum during positive-pressure ventilation by facemask.

[Anesthetist facing ethylic patient : management and precaution]. / L'anesthésiste face à un patient éthylique : gestion et précautions.

The anesthetic management of the patient with unhealthy alcohol use is challenging. Chronic alcohol intake results in numerous co-morbid diseases, physiologic changes and pharmacologic alterations leading to increased perioperative morbidity and mortality. Hence anesthesiologists should search for chronic and acute effects of alcohol abuse when managing such patients. Also, the anesthetic approach of these patients must be adapted to prevent perioperative complications, including withdrawal symptoms. Last, the preoperative period is on opportunity to initiate alcohol withdrawal, with patient's agreement and collaboration.

La gestion anesthésique du patient ayant une consommation d'alcool pathologique est difficile. La consommation chronique d'alcool entraîne de nombreuses pathologies, des modifications physiologiques et des changements pharmacologiques, entraînant une augmentation de la morbidité et de la mortalité périopératoires. Par conséquent, les anesthésistes doivent rechercher les effets chroniques et aigus de l'abus d'alcool lors de la prise en charge de tels patients. En outre, l'approche anesthésique de ces patients doit être adaptée pour prévenir les complications périopératoires, y compris les symptômes de sevrage. Enfin, la période préopératoire est l'occasion de commencer le sevrage alcoolique, avec l'accord et la collaboration du patient.

[An unexpected discovery of laryngeal neurofibroma during intubation for elective surgery]. / Le cas clinique du mois. Découverte fortuite d'un neurofibrome laryngé lors d'une intubation chez une patiente atteinte de neurofibromatose de type 1.

We report the unexpected discovery of a large laryngeal neurofibroma during a direct laryngoscopy for intubation in a 18-year old female with a medical history of neurofibromatosis type 1. The most striking feature of this case report is the discrepancy between the absence of clinical manifestations and the size and location of the neurofibroma. This case highlights the importance of a careful preoperative assessment, especially in the context of multisystemic disease. Knowledge of the disease, recognition of related complications and adequate preoperative evaluation are crucial to establish the safest anesthesia strategy.

Nous rapportons la découverte fortuite d'un volumineux neurofibrome laryngé lors de la laryngoscopie précédant une intubation endotrachéale chez une patiente de 18 ans atteinte d'une neurofibromatose de type 1, par ailleurs asymptomatique. Ce cas est remarquable par l'absence de toute manifestation clinique rapportée par la patiente malgré le volumineux neurofibrome présent dans le larynx. Il souligne l'importance d'une mise au point préopératoire approfondie, particulièrement dans le cas de maladies multisystémiques. Une bonne connaissance de cette maladie et de ses complications est indispensable pour réaliser un bilan préopératoire adéquat et déterminer la stratégie d'anesthésie la plus adaptée à ces patients.

Intravenous infusion of lidocaine significantly reduces propofol dose for colonoscopy: a randomised placebo-controlled study.

BACKGROUND: Propofol use during sedation for colonoscopy can result in cardiopulmonary complications. Intravenous lidocaine can alleviate visceral pain and decrease propofol requirements during surgery. We tested the hypothesis that i.v. lidocaine reduces propofol requirements during colonoscopy and improves post-colonoscopy recovery. METHODS: Forty patients undergoing colonoscopy were included in this randomised placebo-controlled study. After titration of propofol to produce unconsciousness, patients were given i.v. lidocaine (1.5 mg kg-1 then 4 mg kg-1 h-1) or the same volume of saline. Sedation was standardised and combined propofol and ketamine. The primary endpoint was propofol requirements. Secondary endpoints were: number of oxygen desaturation episodes, endoscopists' working conditions, discharge time to the recovery room, post-colonoscopy pain, fatigue. RESULTS: Lidocaine infusion resulted in a significant reduction in propofol requirements: 58 (47) vs 121 (109) mg (P=0.02). Doses of ketamine were similar in the two groups: 19 (2) vs 20 (3) mg in the lidocaine and saline groups, respectively. Number of episodes of oxygen desaturation, endoscopists' comfort, and times for discharge to the recovery room were similar in both groups. Post-colonoscopy pain (P<0.01) and fatigue (P=0.03) were significantly lower in the lidocaine group. CONCLUSIONS: Intravenous infusion of lidocaine resulted in a 50% reduction in propofol dose requirements during colonoscopy. Immediate post-colonoscopy pain and fatigue were also improved by lidocaine. CLINICAL TRIAL REGISTRATION: NCT 02784860.

Propofol-induced unresponsiveness is associated with impaired feedforward connectivity in cortical hierarchy.

BACKGROUND: Impaired consciousness has been associated with impaired cortical signal propagation after transcranial magnetic stimulation (TMS). We hypothesised that the reduced current propagation under propofol-induced unresponsiveness is associated with changes in both feedforward and feedback connectivity across the cortical hierarchy. METHODS: Eight subjects underwent left occipital TMS coupled with high-density EEG recordings during wakefulness and propofol-induced unconsciousness. Spectral analysis was applied to responses recorded from sensors overlying six hierarchical cortical sources involved in visual processing. Dynamic causal modelling (DCM) of induced time-frequency responses and evoked response potentials were used to investigate propofol's effects on connectivity between regions. RESULTS: Sensor space analysis demonstrated that propofol reduced both induced and evoked power after TMS in occipital, parietal, and frontal electrodes. Bayesian model selection supported a DCM with hierarchical feedforward and feedback connections. DCM of induced EEG responses revealed that the primary effect of propofol was impaired feedforward responses in cross-frequency theta/alpha-gamma coupling and within frequency theta coupling (F contrast, family-wise error corrected P<0.05). An exploratory analysis (thresholded at uncorrected P<0.001) also suggested that propofol impaired feedforward and feedback beta band coupling. Post hoc analyses showed impairments in all feedforward connections and one feedback connection from parietal to occipital cortex. DCM of the evoked response potential showed impaired feedforward connectivity between left-sided occipital and parietal cortex (T contrast P=0.004, Bonferroni corrected). CONCLUSIONS: Propofol-induced loss of consciousness is associated with impaired hierarchical feedforward connectivity assessed by EEG after occipital TMS.

Brain functional connectivity differentiates dexmedetomidine from propofol and natural sleep.

BACKGROUND: We used functional connectivity measures from brain resting state functional magnetic resonance imaging to identify human neural correlates of sedation with dexmedetomidine or propofol and their similarities with natural sleep. METHODS: Connectivity within the resting state networks that are proposed to sustain consciousness generation was compared between deep non-rapid-eye-movement (N3) sleep, dexmedetomidine sedation, and propofol sedation in volunteers who became unresponsive to verbal command. A newly acquired dexmedetomidine dataset was compared with our previously published propofol and N3 sleep datasets. RESULTS: In all three unresponsive states (dexmedetomidine sedation, propofol sedation, and N3 sleep), within-network functional connectivity, including thalamic functional connectivity in the higher-order (default mode, executive control, and salience) networks, was significantly reduced as compared with the wake state. Thalamic functional connectivity was not reduced for unresponsive states within lower-order (auditory, sensorimotor, and visual) networks. Voxel-wise statistical comparisons between the different unresponsive states revealed that thalamic functional connectivity with the medial prefrontal/anterior cingulate cortex and with the mesopontine area was reduced least during dexmedetomidine-induced unresponsiveness and most during propofol-induced unresponsiveness. The reduction seen during N3 sleep was intermediate between those of dexmedetomidine and propofol. CONCLUSIONS: Thalamic connectivity with key nodes of arousal and saliency detection networks was relatively preserved during N3 sleep and dexmedetomidine-induced unresponsiveness as compared to propofol. These network effects may explain the rapid recovery of oriented responsiveness to external stimulation seen under dexmedetomidine sedation. TRIAL REGISTRY NUMBER: Committee number: 'Comité d'Ethique Hospitalo-Facultaire Universitaire de Liège' (707); EudraCT number: 2012-003562-40; internal reference: 20121/135; accepted on August 31, 2012; Chair: Prof G. Rorive. As it was considered a phase I clinical trial, this protocol does not appear on the EudraCT public website.

Transversus abdominis plane block or intravenous lignocaine in open prostate surgery: a randomized controlled trial.

BACKGROUND AND OBJECTIVES: Transversus abdominis plane block (TAP) and intravenous lignocaine are two analgesic techniques frequently used after abdominal surgery. We hypothesized that these two techniques improve post-operative analgesia after open prostate surgery and sought to compare their efficacy on immediate post-operative outcome after open prostate surgery. METHODS: After ethics committee approval, 101 patients were enrolled in this prospective study and randomly allocated to receive bilateral ultrasound-guided TAP (n = 34), intravenous lignocaine (n = 33) or placebo (n = 34). In addition, intravenous paracetamol was given every 6 h. The primary endpoint was the cumulative opioid consumption during the first 48 post-operative hours (median[IQR]). Secondary endpoints included pain scores at rest and upon coughing, need for rescue tramadol, incidence of post-operative nausea and vomiting (PONV), recovery of bowel function and incidence of bladder catheter-related discomfort. RESULTS: Cumulative piritramide consumption after 48 h was 28 [23] mg in the control group, 21 [29] mg in the TAP group and 21 [31] mg in the lignocaine group (P = 0.065). There was no significant difference in post-operative pain scores between groups. The proportions of patients requiring rescue tramadol, experiencing PONV or bladder catheter-related discomfort were similar in each group. Recovery of bowel function was also similar in the three groups. CONCLUSIONS: Our study suggests that TAP block and intravenous lignocaine do not improve the post-operative analgesia provided by systematic administration of paracetamol after open prostatectomy.

[PERIOPERATIVE VISUAL LOSS AFTER SPINE SURGERY: A CASE REPORT]. / Cécité post-opératoire après chirurgie rachidienne.

Perioperative visual loss is a rare but devastating complication that may follow spine surgery in the prone position. So far, the incidence, mechanisms and risk factors have not been clearly established. Most commonly, the visual loss results from an ischemic optic neuropathy. We describe the case of a 68 year-old woman who underwent a lumbar laminectomy in the prone position. Upon recovery from anesthesia, the patient complained of total left blindness. This visual loss was, slowly and only partially, recovered after 72 hours. We discuss the most common causes of postoperative visual loss, the risk factors and preventive strategy.

[Regional anesthesia: an extra-benefit for our patients]. / L'anesthésie locorégionale, un plus pour nos patients ....

Regional anesthesia is gaining popularity. It provides various benefits, including high quality postoperative analgesia. This leads to a diminished postoperative opioid consumption, less sensitization of peripheral and central neurons, and a reduced risk of persistent chronic pain. Moreover, regional blocks optimize functional recovery after surgery and improve the outcome of cancer patients who undergo surgery. They also reduce the risk of postoperative complications, especially wound complications. Also, regional blocks are frequently used in the management of chronic pain. Finally, in recent years, technological progress (such as the use of ultrasonography) has made these anesthesia techniques safer and more comfortable for the patient.

[When diagnostic imaging is misleading: a case of subacute liver failure]. / LE CAS CLINIQUE DU MOIS. Quand l'imagerie nous induit en erreur: à propos d'un cas d'insuffisance hépatique subaiguë.

We report the case of a 67 year old woman presenting with a mixed alteration of liver function tests. Despite normal results of tomodensitometry and positon emission tomography, a liver biopsy was performed due to the development of acute liver failure: it showed a diffuse infiltration of liver sinusoids by a breast adenocarcinoma, unfortunately fatal for the patient. The tumour infiltration was responsible for portal hypertension and hepatic perfusion disorders leading to liver failure.

Recruitment of lung volume during surgery neither affects the postoperative spirometry nor the risk of hypoxaemia after laparoscopic gastric bypass in morbidly obese patients: a randomized controlled study.

BACKGROUND: Intraoperative recruitment manoeuvres (RMs) combined with PEEP reverse the decrease in functional residual capacity (FRC) associated with anaesthesia and improve intraoperative oxygenation. Whether these benefits persist after operation remains unknown. We tested the hypothesis that intraoperative RMs associated with PEEP improve postoperative spirometry including FRC and reduce the incidence of postoperative hypoxaemia in morbidly obese (MO) patients undergoing laparoscopic gastric bypass. METHODS: After IRB approval and informed consent, 50 MO patients undergoing laparoscopic gastric bypass under volume-controlled ventilation (tidal volume 6 ml kg(-1) of IBW) were randomly ventilated with either 10 cm H2O PEEP or with 10 cm H2O PEEP and one RM carried out after induction of pneumoperitoneum, and another after exsufflation. Anaesthesia and analgesia were standardized. Spirometry was assessed before operation and 24 h after surgery. Postoperative oxygenation and the apnoea-hypopnoea index (AHI) were recorded during the first postoperative night. RESULTS: Age, BMI, and STOP BANG score were similar in both groups. FRC decrease after surgery was minimal [0.15 (0.14) litre in control and 0.38 (0.19) litre in the RM group] and similar between the groups (P=0.35). FVC, FEV1, mean [Formula: see text], percentage of time spent with [Formula: see text] below 90%, and AHI did not differ significantly between the groups. CONCLUSIONS: This study demonstrates that when added to a protective mechanical ventilation combining low tidal volume and high PEEP, two RMs do not improve postoperative lung function including FRC, arterial oxygenation, and the incidence of obstructive apnoea in MO patients after laparoscopic upper abdominal surgery. CLINICAL TRIAL REGISTRATION: EudraCT 2011-000999-33.

Preeclampsia: an update.

Preeclampsia was formerly defined as a multisystemic disorder characterized by new onset of hypertension (i.e. systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg) and proteinuria (> 300 mg/24 h) arising after 20 weeks of gestation in a previously normotensive woman. Recently, the American College of Obstetricians and Gynecologists has stated that proteinuria is no longer required for the diagnosis of preeclampsia. This complication of pregnancy remains a leading cause of maternal morbidity and mortality. Clinical signs appear in the second half of pregnancy, but initial pathogenic mechanisms arise much earlier. The cytotrophoblast fails to remodel spiral arteries, leading to hypoperfusion and ischemia of the placenta. The fetal consequence is growth restriction. On the maternal side, the ischemic placenta releases factors that provoke a generalized maternal endothelial dysfunction. The endothelial dysfunction is in turn responsible for the symptoms and complications of preeclampsia. These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures. Despite a better understanding of preeclampsia pathophysiology and maternal hemodynamic alterations during preeclampsia, the only curative treatment remains placenta and fetus delivery. At the time of diagnosis, the initial objective is the assessment of disease severity. Severe hypertension (SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg), thrombocytopenia < 100.000/µL, liver transaminases above twice the normal values, HELLP syndrome, renal failure, persistent epigastric or right upper quadrant pain, visual or neurologic symptoms, and acute pulmonary edema are all severity criteria. Medical treatment depends on the severity of preeclampsia, and relies on antihypertensive medications and magnesium sulfate. Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures. The decision of terminating pregnancy and perform delivery is based on gestational age, maternal and fetal conditions, and severity of preeclampsia. Delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation. Between 24 and 34 weeks of gestation, conservative management of severe preeclampsia may be considered in selected patients. Antenatal corticosteroids should be administered to less than 34 gestation week preeclamptic women to promote fetal lung maturity. Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks of gestation. Maternal end organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age. Neuraxial analgesia and anesthesia are, in the absence of thrombocytopenia, strongly considered as first line anesthetic techniques in preeclamptic patients. Airway edema and tracheal intubation-induced elevation in blood pressure are important issues of general anesthesia in those patients. The major adverse outcomes associated with preeclampsia are related to maternal central nervous system hemorrhage, hepatic rupture, and renal failure. Preeclampsia is also a risk factor for developing cardiovascular disease later in life, and therefore mandates long-term follow-up.