[Proposal of guidelines for antibiotic prophylaxis in plastic, reconstructive, and aesthetic surgery]. / Proposition de recommandations sur l'antibioprophylaxie en chirurgie plastique, reconstructrice et esthétique.

BACKGROUND: In plastic surgery, guidelines about antibiotic prophylaxis are inaccurate and incomplete, due to result the absence of high-level studies on this subject. The main aim is to establish national common recommendations for plastic surgery antibiotic prophylaxis. MATERIALS AND METHODS: A working group will discuss and validate a multi-center analysis of practices in three University Hospital Centers compared to an interdisciplinary analysis of recommendations to the French Society of Anaesthesia and Intensive Care Medicine and scientific literature. This working group is composed of plastic surgeon members of the French Society of Aesthetic Reconstructive Plastic Surgery, infectious disease physicians, and anaesthesiologists to define clear and precise antibiotic prophylaxis recommendations. RESULTS: Antibiotic prophylaxis with cefazoline (or clindamycine±gentamicine in case of allergy), has been recommended for general surgery with flap or implants, for breast surgery, lipofilling, and rhinoplasty. In other plastic surgery, no antibiotic prophylaxis has been recommended. CONCLUSION: We established common recommendations for plastic surgery antibiotic prophylaxis that is the first step to update these recommendations. Now, they can be evaluated in clinical situation to validate them.

Anaesthetic hypersensitivity reactions in France between 2011 and 2012: the 10th GERAP epidemiologic survey.

BACKGROUND: Immediate hypersensitivity reactions during anaesthesia are rare but potentially life-threatening. The epidemiology changes with time and evolving professional practice, and hence needs to be monitored. Our objective was to follow this epidemiology. METHODS: This was a retrospective, observational study in French hospital clinics, conducted by GERAP members (Groupe d'Étude des Réactions Anaphylactoïdes Périopératoires). Consecutive patients seen in allergo-anaesthesia outpatient clinics, who had experienced a hypersensitivity reaction during anaesthesia between 1 January 2011 and 31 December 2012, were included. Demographic data, allergy history, drugs received before the reaction, symptoms of the reaction, results of blood samples (histamine, tryptase, IgE-specific assays), and results of the allergy assessment were recorded. RESULTS: The most common causes of allergic reactions were (Neuromuscular Blocking Agents) NMBAs (N = 302; 60.6%), antibiotics (N = 91, 18.2%, Cephalosporin N = 49, 10%) and dyes (N = 27; 5.4%). Latex as an allergic agent was involved in 26 cases (5.2%), hypnotics in 11 cases (2.2%) and opioids in seven cases (1.4%). Of the NMBAs, Rocuronium had the highest proportion of reactions (13.8 reactions/100,000 vials sold) followed by Suxamethonium (13.3/100,000 vials sold). Cisatracurium had the lowest proportion of reactions (0.4/100,000 vials sold). Patients were sensitized to two or more NMBAs in 48.9% of cases and without testing, cross-sensitivity cannot be predicted. CONCLUSIONS: When compared with the previous GERAP studies, NMBAs are still the most frequently triggering allergens, with marked differences between individual NMBAs, but they are now followed by antibiotics (of which greater than 50% were cephalosporins) and dyes. Anaesthetists must be aware of the differences between drugs and of the pattern of emerging allergens. For the future of safe anaesthesia, allergy assessment is essential.

6% Hydroxyethyl starch (130/0.4) vs Ringer's lactate preloading before spinal anaesthesia for Caesarean delivery: the randomized, double-blind, multicentre CAESAR trial.

BACKGROUND: Vasopressor administration is recommended to prevent hypotension during spinal anaesthesia (SA) for elective Caesarean delivery. We aimed to test the superior efficacy and ensure safety of a hydroxyethyl starch (HES) vs a Ringer's lactate (RL) preloading, when combined with a phenylephrine-based prophylaxis. METHODS: A total of 167 healthy parturients undergoing elective Caesarean delivery under SA were included in this multicentre, randomized, double-blind study. Patients received 500 ml of 6% HES (130/0.4)+500 ml of RL (HES group) or 1000 ml of RL (RL group) i.v. before SA. After SA, i.v. phenylephrine boluses were titrated when systolic arterial pressure (SAP) was below 95% of baseline. The primary outcome was the incidence of maternal hypotension (SAP <80% of baseline). RESULTS: The incidence of both hypotension and symptomatic hypotension (i.e. with dizziness, nausea/vomiting, or both) was significantly lower in the HES group vs the RL group: 36.6% vs 55.3% (one-sided P=0.025) and 3.7% vs 14.1%. There was no significant difference in total phenylephrine requirements [median (range): 350 (50-1800) vs 350 (50-1250) µg]. The decrease in maternal haemoglobin value the day after surgery was similar in the two groups [1.2 (1.0) vs 1.0 (0.9) g dl(-1)]. There was no detectable placental transfer of HES in six umbilical cord blood samples analysed in the HES group. Neonatal outcomes were comparable between the groups. CONCLUSIONS: Compared with a pure RL preloading, a mixed HES-RL preloading significantly improved prevention of both hypotension and symptomatic hypotension based on early phenylephrine bolus administration and did not induce adverse effects. CLINICAL TRIAL REGISTRATION: NCT00694343 (http://clinicaltrials.gov).

Hypersensitivity reactions to Patent Blue V in breast cancer surgery: a prospective multicentre study.

BACKGROUND: An increasing number of immediate hypersensitivity reactions (HSR) have been reported after the use of Patent Blue V (PBV) for breast cancer surgery. This is the first study to publish prospective data with systematic allergological assessment. METHODS: We conducted a multicentre study in 10 French cancer centres for over 6 months. All patients scheduled for breast surgery with injection of PBV were included in the study. Patients were screened for past medical history, atopy, and known food and drug allergies. When suspected HSR or unexplained reactions occurred after injection of PBV, blood samples were taken, and plasma histamine and serum tryptase concentrations were measured. HSR to PBV was suggested if skin tests performed 6 weeks later were positive. RESULTS: Nine suspected HSR to PBV were observed in 1742 patients. Skin tests were positive in six patients, giving an incidence of 0.34%. Four grade I and two grade III HSR were observed, both requiring intensive care unit treatment. Mean onset time of the reaction was 55 ± 37 min. Plasma histamine was elevated in four patients, while serum tryptase was normal. We found no risk factors associated with HSR to PBV. CONCLUSION: An incidence rate of one in 300 HSR to PBV was observed for patients exposed to PBV during sentinel lymph node detection. This rate is higher than rates reported after the use of neuromuscular blocking agents, latex or antibiotics.

Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice.

These guidelines represent the updated consensus of experts in the field of immediate hypersensitivity reactions occurring during anesthesia. They provide a series of valid, widely accepted, effective, and easily teachable guidelines that are the fruit of current knowledge, research, and experience. The guidelines are based on the findings of international scientific research and have been implemented in France under the auspices of the French Society for Anaesthesia and Intensive Care (Société Française d'Anesthésie et de Réanimation [SFAR]) and the French Society of Allergology (Société Française d'Allergologie [SFA]). The members of the European Network for Drug Allergy approved the guidelines. This paper presents the most relevant clinical implications of the guidelines.

Anaphylactic reaction to hydroxyzine in an anesthetized patient.

A case of anaphylaxis occurring during a general anesthesia is presented. The reaction was severe with bronchospasm and hypotension (grade 2 in the severity of per-operative anaphylactic shock). The responsibility of hydroxyzine, administered for premedication was suspected by intradermal testing with the molecule, which was twice positive at a 10(-2) dilution of the commercial solution. The same test remained negative in 5 control subjects. All the other drugs received during anesthesia gave negative results. Using the same protocol excepted for the use of hydroxyzine a new general anesthesia could be performed under a premedication with dexchlorpheniramine without any allergic reaction. Anaphylactic reactions are very rare with hydroxyzine used in premedication for anesthesia in regard to the large prescription of the drug. Only two previous cases were reported but attention of the allergist must be also pointed towards the medications received in the perioperative period as for the anesthetic drugs.

Systematic follow-up increases incidence of anaphylaxis during adverse reactions in anesthetized patients.

BACKGROUND: The incidence of hypersensitivity reactions during anesthesia is underestimated because clinical symptoms may vary and diagnosis is not obvious. Our aim was to investigate the consequences of a systematic follow-up of patients on the estimated incidence of allergic reactions during anesthesia. METHODS: We conducted a prospective study over a 2-year period (70,000 anesthesias). When patients were suspected with hypersensitivity reactions or with unexplained adverse reactions during anesthesia, blood was sampled to measure histamine and tryptase, and then skin tests were performed 4-6 weeks later. RESULTS: During the studied period, 39 patients were enrolled in the database. Eight were excluded because of lack of skin tests. Twenty-two patients had clinical features compatible with immediate hypersensitivity reaction, and nine had reactions rated as 'unexplained' by the attending physician. Following systematic investigation, we found 22 hypersensitivity reactions (15 patients with obvious and seven with unexplained reactions) during anesthesia. This increases the estimated incidence of hypersensitivity reactions from 1 : 4667 to 1 : 3180 anesthesias. Tryptase concentrations were increased in only 50% of these patients. In our series, positive and negative predictive values of tryptase at T(0) for the diagnosis of anaphylaxis were 100% and 60%, respectively. Latex was the major causative agent, followed by neuromuscular blocking agents and antibiotics. CONCLUSIONS: Systematic follow-up of patients with unexplained reactions during anesthesia increases the estimated incidence of IgE-mediated hypersensitivity reactions during anesthesia by 50%.

Effect of epinephrine on epidural, intrathecal, and plasma pharmacokinetics of ropivacaine and bupivacaine in sheep.

BACKGROUND: Local vasoconstriction induced by epinephrine added to epidural local anaesthetics has been shown to improve their quality and duration of action in several clinical reports. There are several assumptions on the mechanisms. This study was designed to evaluate the influence of epinephrine on transmeningeal uptake of epidurally administered ropivacaine and bupivacaine by measuring local anaesthetic concentrations in the epidural and intrathecal spaces and in plasma. METHODS: Ropivacaine (50 mg) and bupivacaine (30 mg) were administered epidurally in sheep with and without epinephrine (75 microg). A microdialysis technique was used to simultaneously measure epidural and intrathecal drug concentrations. Resulting dialysate and plasma concentrations were used to calculate pharmacokinetic parameters for ropivacaine and bupivacaine. RESULTS: Co-administration of epinephrine decreased epidural clearance for ropivacaine [0.6 (sd 0.1) vs 0.4 (0.1) ml min(-1)] but not significantly for bupivacaine [1.2 (0.4) vs 0.8 (0.3) ml min(-1)]. The resultant increase in epidural area under the concentration-time curves (31% for ropivacaine and 52% for bupivacaine) was also observed in the intrathecal space (21% increase for ropivacaine and 37% for bupivacaine). There was no significant influence of epinephrine on ropivacaine plasma pharmacokinetics. Plasma Cmax for bupivacaine was decreased. CONCLUSIONS: These results show that epinephrine decreases the clearance and distribution processes involved in epidural disposition of ropivacaine and bupivacaine, leading to an increased uptake into the intrathecal space with an apparent more pronounced effect for bupivacaine.

Labor analgesia and cesarean section in women affected by tuberous sclerosis: report of two cases.

Tuberous sclerosis is a multi-system disease characterized by the presence of benign growths in many tissues, mostly localized in skin, brain, kidney and lungs. Epileptic seizures and renal hemorrhage are frequent in such patients. Apart from life-threatening hemorrhage after rupture of angiomyolipomatoma, few data are available about anesthetic considerations during pregnancy. We report two cases of pregnant patients with tuberous sclerosis, one scheduled for medical termination of pregnancy at 27 weeks of gestational, the other a cesarean section for breech presentation under general anesthesia. We review and discuss the ability to perform regional anesthesia in each case.

[Evaluation of enhanced recovery for elective cesarean section]. / Évaluation de la mise en place d'un protocole de réhabilitation précoce postcésarienne.

OBJECTIVE: To evaluate the implementation of a protocol of enhanced recovery for elective cesarean section in a level III maternity. METHODS: This is a prospective observational study such as "before/after" on the implementation of a protocol of enhanced recovery for elective cesarean section from January 1st to December 31st, 2015, in a level III obstetrics unit French maternity. Patients were separated in 2 groups: women who benefit from enhanced recovery protocol after the first of July compared to women who underwent the conventional protocol between January 1st and June 30th, 2015. Inclusion criteria included: performing an emergency or scheduled cesarean, in patients with medical history congruent with the possible hospital release at day three. Demographic and obstetrics data were gathered. Items of the protocol, adverse and secondary effects as well as, postoperative complications were collected. RESULTS: From January 1st to December 31st 2015, 408 patients were included in this study, 202 in the conventional arm protocol and 206 in the enhanced recovery protocol. Early rehabilitation protocol has been achieved for 25.7 % patients (n=105) with 18.1 % (n=19) before the establishment of the protocol and 81.9 % (n=86) after creation of the latter. Prevention of PONV by dexamethasone and droperidol was performed before and after creation of the protocol in 5.3 % (n=1) and 51.2 % of cases (n=44) (P<0.05), respectively. There were no significant differences between the 2 groups regarding the removal of the urinary catheter (94.7 % versus 76 %, P=0.14) or the shutter venous catheter SSPI (78.9 % vs 73 %, P=0.82). Administration of drinks H1 and H4 first meal were routinely performed after the creation of the protocol (52.6 % vs 100 %, P<0.05 and 63.1 % vs 100 %, P<0.05). An early rise in the first 12hours was usually performed after the drafting of the protocol (78.9 % versus 92 %, P<0.05). Average hospital stay was shorter after the establishment of early rehabilitation protocol (4 versus 5.5 days, P<0.05). CONCLUSION: Early rehabilitation protocol was applied safely. It resolved in good management of pain, nausea and vomiting in postoperative. It participated in reducing adverse outcomes that could slow recovery and therefore allowed earlier hospital discharge, while maintaining high level of satisfaction with their care.

[Anaesthesia and prostate surgery]. / Anesthésie et chirurgie de la prostate.

OBJECTIVES: To review the current data about anaesthetic management in prostate surgery with special regards on analysis and prevention of specific risks, appropriate anaesthetic procedure keeping with surgery and patient, recognition and treatment of adverse events. DATA SOURCES AND EXTRACTION: The Pubmed database was searched for articles (1990-2004) combined with references analysis of major articles on the field. DATA SYNTHESIS: It is strongly recommended to settle germfree urine in the preoperative period. The thromboembolic risk of radical retropubic prostatectomy for cancer parallels lower abdomen oncologic surgery and is prolonged. Preoperative evaluation of cardiovascular, respiratory, neurological and metabolic comorbidity is a source of prognostic information and an essential tool in the management of elderly patients with prostate disease. Extreme patient positioning applied in prostate surgery induces haemodynamic and respiratory changes and are associated with severe muscular and nervous injuries. The laparoscopic access for radical prostatectomy is a growing alternative to the open surgical procedure. Acute normovolaemic haemodilution is a consistent and cost-effective blood conservation strategy in reducing allogenic blood transfusion for radical retropubic prostatectomy. Whether open transvesical or transurethral prostatectomy for treatment of benign hypertrophy depends on the size of the gland: transurethral resection is safe up to 80 g. Intrathecal anaesthesia with a T9 cephalad spread of sensory block, produces adequate conditions for transurethral prostatectomy and allows a rapid diagnosis of irrigating fluid absorption syndrome. In spite of recommended preoperative antibiotic prophylaxis, bacteriemias are frequent during transurethral prostate resection.

A dose-response study of epidural liposomal bupivacaine in rabbits.

Liposomes are drug delivery systems used to prolong local effects of bupivacaine. We studied the relationships between motor and hemodynamic changes and epidural doses of plain bupivacaine (P) and liposomal bupivacaine (L) in rabbits equipped with chronical lumbar epidural and femoral arterial catheters. Liposomal (phosphatidylcholine-cholesterol) suspensions contained 20 mg ml-1 of lipid, and different doses of bupivacaine (Lipo 7.5=7.5-; Lipo 3.7=3. 75-; Lipo 2.5=2.5-; Lipo 1.2=1.25-; and Lipo 0.7=0.65-mg of bupivacaine per ml). Forty rabbits were randomly assigned to five groups to receive epidural anesthesia (1 ml) as follows: Groups I to V received 0.65 to 7.5 mg of bupivacaine as P then as L. Release rate of bupivacaine from liposome was significantly slower using Lipo 3.7 than after Lipo 2.5 (Td was 3.9 h and 1.7 h respectively). Increasing the doses of L and P resulted in faster onset time for complete motor blockade and in a prolonged duration of motor effects. Liposomal formulation appears to be a powerful delivery system to prolong the motor effects of bupivacaine since E50 was lower and Emax higher than after the use of plain solution (E50 4.49+/-1.81 mg and Emax 152+/-40 min for P; and E50 2.61+/-0.23 mg and Emax 202+/-9 min for L). Hemodynamic changes were linearly related to doses of bupivacaine injected. The best bupivacaine-to-lipid ratio to prolong motor effects using our model was 3.75 mg and 20.0 mg respectively (Lipo 3.7).

In vitro and in vivo microdialysis calibration using retrodialysis for the study of the cerebrospinal distribution of bupivacaine.

Microdialysis coupled to HPLC was used to study the disposition of local anesthetics in the cerebrospinal fluid (CSF) because of the difficulty in sampling CSF. A retrodialysis method for the microdialysis calibration was investigated in vitro and in vivo. Calibration by retrodialysis was simultaneously validated through the use of the zero net flux method. Two local anesthetics (bupivacaine and ropivacaine), which differ structurally by only one methyl group, were respectively utilized as substance of interest and as internal standard. Different parameters were tested in vitro to compare the relative recovery (RR) of bupivacaine and the relative loss (RL) of ropivacaine. Several flow rates were tried to select an optimal in vivo flow rate (1 microliter/min). the RR and RL values were not influenced by the variation of bupivacaine concentration. A significant variability among different probes within a batch was established (RR ranging from 41.1-65.3%; RL ranging from 30.7-61.0%). The K-factor values, defined as RLropivacaine/RLbupivacaine, were calculated in vitro and in vivo. This ratio decreased in vivo but was constant (K in vitro = 1.06 +/- 0.04, K in vivo = 0.87 +/- 0.03). The extracellular tissue concentration of the compound of interest was again in vitro and no deterioration of probe during the in vivo experiment was found. After administration of bupivacaine in the epidural space of rabbits, plasma and microdialysis CSF samples were simultaneously collected. Plasma and CSF disposition of bupivacaine displayed different kinetics. The maximum CSF concentration of B averaged 394 +/- 170 micrograms ml-1 with a mean Tmax of 3.8 +/- 1.8 min. The maximum CSF concentration of B averaged 0.44 +/- 0.09 micrograms ml-1 with a mean Tmax occurring at 1 min. Microdialysis, combined with accurate calibration, should be a reliable technique to gain further insight in the spinal disposition of local anesthetics.

[Neurotoxicity of intrathecally administrated agents]. / Neurotoxicité des agents administrés par voie intrathécale.

Spinal anaesthetics can induce histopathologic lesions and regional haemodynamic alterations in the spinal cord. There are numerous causes of neurologic lesions, including direct trauma of the spinal cord and nerve roots during puncture or catheter insertion, compromised spinal cord perfusion and direct neurotoxic effect. Histopathologic lesions are localized either in meninges (meningitis or arachnoiditis) or in neuraxis (myelitis or axonal degeneration). Neurotoxicity can result from decrease in neuronal blood supply, elicited by high concentrations of the solutions, long duration exposure to local anaesthetics, and the use of adjuvants. They have been implicated in the occurrence of cauda equina syndrome after continuous spinal anaesthesia using hyperbaric solution of lidocaine and tetracaine given through small diameter catheters. Selective spinal analgesia is induced by spinal opioids without motor blockade except for meperidine. Complications occurred in patients after high doses of morphine, which were related to one of its metabolites, morphine-3-glucuronide. Preservative-free opioid solutions are to be preferred for spinal anaesthesia. There is no report of neurotoxicity neither in animal studies, nor in humans, using spinal clonidine. In order to reduce the incidence of neurotoxicity, some safety rules should be followed. The lowest efficient dose of local anaesthetics must be given. Incomplete blockade should not necessarily lead to a reinjection. Large volume of hyperbaric lidocaine or repeated injections of such solutions must be avoided as well as preservative-containing solutions. The administration of new compounds by the spinal route must be supported by data of spinal neuropharmacology and the lack of neurotoxicity must have been previously checked with animal studies.

[Assessment of teaching methods of anaesthesiology and intensive care medicine in France: opinions of teacher and residents]. / Modalités de l'évaluation de l'enseignement de l'anesthésie-réanimation en France: point de vue des enseignants et des internes.

OBJECTIVE: The objective of this study was to provide informations about French practice of anaesthesiology and intensive care graduation. STUDY DESIGN: Prospective study. MATERIAL AND METHODS: [corrected] Surveys relative to evaluation tools were sent to professors, and students in anaesthesiology and intensive care in France. RESULT: About 95% of French students in anaesthesiology and intensive care want to be evaluated all over their cursus, by using "Carnet de stage", tutor-student agreement or written examinations. Pedagogical evaluation is hardly wished by students and professors despite that "Carnet de stage" and written examinations are frequently used before professional certification. In order to improve the professional competence, the patronage and use of simulator are frequently quoted by professors. CONCLUSION: Despite the fact that "Carnet de stage" and written examinations are frequently used, pedagogic dimension of evaluation need to be improved.

[Interest and feasibility of a modified supine position for posterior cranial fossa surgical procedures]. / Chirurgie de la fosse postérieure en décubitus dorsal modifié: faisabilité et intérêt.

The sitting position is considered as a gold standard for posterior fossa surgical procedures. However, in order to decrease the incidence rate of cerebral venous air embolisms, we presently described a modified supine position allowing performance of posterior fossa surgical procedures. Such position is easy and quickly performed with light variations of blood pressure: patients are placed supine with paddings inserted under ipsilateral shoulder and buttock, and head turned to other side of surgical site. Dural tension estimated by the surgeon was always considered as good. We performed more than 100 surgical procedures in this position without any complication for 10 years.

[Discitis after spinal anesthesia for transurethral resection of the prostate]. / Spondylodiscite après rachianesthésie pour résection transurétrale de prostate.

We described a case of discitis and meningitis following spinal anaesthesia for transurethral resection of the prostate. The patient received antibiotics for a month before surgery, because of Klebsiella prostatitis. Spinal anaesthesia was performed in L3-L4 interspace by using 22G Quincke needle. Bacteriaemia occurred during the first postoperative hours. Ten days after spinal anaesthesia, patient suffered from lumbar pain, exacerbated by vertebral percussion, and motor weakness within lower limb, which was marked on right side. MRI examination showed L3-L4 discitis with psoas abcess in regard, and epiduritis marked around L3 right spinal root. CSF examination confirmed meningitis but no bacteria was found. Antibiotics were administered over a 6 weeks period, and then patient discharged from hospital without neurological sequellae. Infectious discitis related to disk puncture during spinal anaesthesia and postoperative bacteriaemia was likely in our patient.