Intraoperative Electroencephalography Alpha-Band Power Is a Better Proxy for Preoperative Low MoCA Under Propofol Compared With Sevoflurane.

BACKGROUND: Preoperative abnormal cognitive status is a risk factor for postoperative complications yet remains underdiagnosed. During propofol general anesthesia, intraoperative electroencephalography (EEG) variables, such as alpha band power (α-BP), correlate with cognitive status. This relationship under sevoflurane is unclear. We investigated whether EEG biomarkers of poor cognitive status found under propofol could be extended to sevoflurane. METHODS: In this monocentric prospective observational study, 106 patients with intraoperative EEG monitoring were included (propofol/sevoflurane = 55/51). We administered the Montreal Cognitive Assessment (MoCA) scale to identify abnormal cognition (low MoCA) 1 day before intervention. EEG variables included delta to beta frequency band powers. Results were adjusted to age and drug dosage. We assessed depth of anesthesia (DoA) using the spectral edge frequency (SEF 95 ) and maintained it within (8-13) Hz. RESULTS: The difference in α-BP between low and normal MoCA patients was significantly larger among propofol patients (propofol: 4.3 ± 4.8 dB versus sevoflurane: 1.5 ± 3.4 dB, P = .022). SEF 95 and age were not statistically different between sevoflurane and propofol groups. After adjusting to age and dose, low α-BP was significantly associated with low MoCA under propofol (odds ratio [OR] [confidence interval {CI}] = 0.39 [0.16-0.94], P = .034), but not under sevoflurane, where theta-band power was significantly associated with low MoCA (OR [CI] = 0.31 [0.13-0.73], P = .007). CONCLUSIONS: We suggest that intraoperative EEG biomarkers of abnormal cognition differ between propofol and sevoflurane under general anesthesia.

Elevated plasma Galectin-3 is associated with major adverse kidney events and death after ICU admission.

BACKGROUND: Galectin-3 (Gal-3) is a proinflammatory and profibrotic protein especially overexpressed after Acute Kidney Injury (AKI). The early renal prognostic value of Gal-3 after AKI in critically ill patients remains unexplored. The objective was to evaluate the prognostic value of plasma level of Gal-3 for Major Adverse Kidney Events (MAKE) and mortality 30 days after ICU admission across AKI stages. METHODS: This is an ancillary study of a prospective, observational, multicenter cohort (FROG-ICU). AKI was defined using KDIGO definition. RESULTS: Two thousand and seventy-six patients had a Gal-3 plasma level measurement at ICU admission. Seven hundred and twenty-three (34.8%) were females and the median age was 63 [51, 74] years. Eight hundred and seven (38.9%) patients developed MAKE, 774 (37.3%) had AKI and mortality rate at 30 days was 22.4% (N = 465). Patients who developed MAKE had higher Gal-3 level at admission compared to patients without (30.2 [20.8, 49.2] ng/ml versus 16.9 [12.7, 24.3] ng/ml, p < 0.001, respectively. The area under the receiver operating characteristic curve of Gal-3 to predict MAKE was 0.76 CI95% [0.74-0.78], p < 0.001. Gal-3 was associated with MAKE (OR 1.80 CI95% [1.68-1.93], p < 0.001, non-adjusted and OR 1.37 CI95% [1.27-1.49], p < 0.001, adjusted). The use of Gal-3 improved prediction performance of prediction model including SAPSII, Screatadm, pNGAL with a NRI of 0.27 CI95%(0.16-0.38), p < 0.001. Median Gal-3 was higher in non-survivors than in survivors at 30 days (29.2 [20.2, 49.2] ng/ml versus 18.8 [13.3, 29.2] ng/ml, p < 0.001, respectively). CONCLUSION: Plasma levels of Gal-3 were strongly associated with renal function, with an increased risk of MAKE and death after ICU admission. Trial registration ClinicalTrials.gov NCT01367093. Registered on 6 June 2011.

Outcomes of Acute Stroke Patients Requiring Mechanical Ventilation: Study Protocol for the SPICE Multicenter Prospective Observational Study.

BACKGROUND: Care pathways and long-term outcomes of acute stroke patients requiring mechanical ventilation have not been thoroughly studied. METHODS AND RESULTS: Stroke Prognosis in Intensive Care (SPICE) is a prospective multicenter cohort study which will be conducted in 34 intensive care units (ICUs) in the Paris, France area. Patients will be eligible if they meet all of the following inclusion criteria: (1) age of 18 years or older; (2) acute stroke (i.e., ischemic stroke, intracranial hemorrhage, or subarachnoid hemorrhage) diagnosed on neuroimaging; (3) ICU admission within 7 days before or after stroke onset; and (4) need for mechanical ventilation for a duration of at least 24 h. Patients will be excluded if they meet any of the following: (1) stroke of traumatic origin; (2) refusal to participate; and (3) privation of liberty by administrative or judicial decision. The primary endpoint is poor functional outcome at 1 year, defined by a score of 4 to 6 on the modified Rankin scale (mRS), indicating severe disability or death. Main secondary endpoints will include decisions to withhold or withdraw care, mRS scores at 3 and 6 months, and health-related quality of life at 1 year. CONCLUSIONS: The SPICE multicenter study will investigate 1-year outcomes, ethical issues, as well as care pathways of acute stroke patients requiring invasive ventilation in the ICU. Gathered data will delineate human resources and facilities needs for adequate management. The identification of prognostic factors at the acute phase will help to identify patients who may benefit from prolonged intensive care and rehabilitation. TRIAL REGISTRATION: NCT03335995.

Using velocity-pressure loops in the operating room: a new approach of arterial mechanics for cardiac afterload monitoring under general anesthesia.

Cardiac afterload is usually assessed in the ascending aorta and can be defined by the association of peripheral vascular resistance (PVR), total arterial compliance (Ctot), and aortic wave reflection (WR). We recently proposed the global afterload angle (GALA) and ß-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta. The aim of this study was to 1) describe the arterial mechanic properties by studying the velocity-pressure relations according to cardiovascular risk (low-risk and high-risk patients) in the ascending and descending thoracic aorta and 2) analyze the association between the VP loop (GALA and ß-angle) and cardiac afterload parameters (PVR, Ctot, and WR). PVR, Ctot, WR, and VP loop parameters were measured in the ascending and descending thoracic aorta in 50 anesthetized patients. At each aortic level, the mean arterial pressure (MAP), cardiac output (CO), and PVR were similar between low-risk and high-risk patients. In contrast, Ctot, WR, GALA, and ß-angle were strongly influenced by cardiovascular risk factors regardless of the site of measurement along the aorta. The GALA angle was inversely related to aortic compliance, and the ß-angle reflected the magnitude of wave reflection in both the ascending and descending aortas (P < 0.001). Under general anesthesia, the VP loop can provide new visual insights into arterial mechanical properties compared with the traditional MAP and CO for the assessment of cardiac afterload. Further studies are necessary to demonstrate the clinical utility of the VP loop in the operating room.NEW & NOTEWORTHY Our team recently proposed the global afterload angle (GALA) and ß-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta under general anesthesia. However, the evaluation of cardiac afterload at this location is unusual. The present study shows that VP loop parameters can describe the components of cardiac afterload both in the ascending and descending thoracic aorta in the operating room. Aging and cardiovascular risk factors strongly influence VP loop parameters. The VP loop could provide continuous visual additional information on the arterial system than the traditional mean arterial pressure and cardiac output during the general anesthesia.

Effect of early use of noradrenaline on in-hospital mortality in haemorrhagic shock after major trauma: a propensity-score analysis.

BACKGROUND: The role of vasopressors in trauma-related haemorrhagic shock (HS) remains a matter of debate. They are part of the most recent European recommendations on the management of HS and are regularly used in France. We assessed the effect of early administration of noradrenaline in 24 h mortality of trauma patients in HS, using a propensity-score analysis. METHODS: The study included patients from a multicentre prospective regional trauma registry. HS was defined as transfusion of ≥4 erythrocyte-concentrate units during the first 6 h. Patients with a Glasgow coma scale=3 and pre-hospital traumatic cardiac arrest were excluded. The main outcome measure was in-hospital mortality. The explicative and adjustment variables for the outcome and treatment allocation were predetermined by a Delphi method. The in-hospital mortality of patients with and without early administration of noradrenaline was compared in a propensity-score model, including all predetermined variables. RESULTS: Of 7141 patients in the registry in the study period, 6353 were screened and 518 patients in HS (201 with early noradrenaline use and 317 without) were included and analysed. After propensity-score matching, 100 patients remained in each group, and the hazard-ratio mortality was 0.95 (95% confidence interval: 0.45-2.01; P=0.69). CONCLUSIONS: The results of the present study suggest that noradrenaline use in the early phase of traumatic HS does not seem to affect mortality adversely. This observation supports a rationale for equipoise in favour of a prospective trial of the use of vasopressors in HS after trauma.

Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension.

INTRODUCTION: During general anesthesia, arterial hypotension is frequent and may be an important contributor to perioperative morbidity. We assessed the effect of a 5 µg bolus of Norepinephrine (NA) when compared with 50 µg bolus of Phenylephrine (PE) administered to treat hypotension during maintenance anesthesia, on MAP, derived cardiac output and arterial stiffness parameters. METHODS: Patients scheduled for a neurosurgical procedure under general anesthesia were prospectively included. Monitoring included invasive blood pressure, esophageal Doppler, and arterial tonometer used to estimate central aortic pressure with arterial stiffness parameters, such as augmentation index (Aix). After initial resuscitation, hypotensive episodes were corrected by a bolus administration of NA or PE in a peripheral venous line. RESULTS: There were 269 bolus administrations of vasopressors (149 NA, 120 PE) in 47 patients with no adverse effects detected. A decrease in stroke volume (SV) was observed with PE compared with NA (-18 ± 9% vs. -14 ± 7%, P < 0.001). This decrease was associated with an increase in Aix, which was greater for PE than for NA (+10 ± 8% vs. +6 ± 6%, P < 0.0001), and a decrease in total arterial compliance greater for PE compared to NA (Ctot = SV/Central Pulse Pressure) (-35 ± 9% vs. -29 ± 10%, P < 0.001). DISCUSSION: This study suggests that 5 µg of NA administered as a bolus in a peripheral venous line could treat general anesthesia-induced arterial hypotension with a smaller decrease in SV and arterial compliance when compared to PE.

Comparison of cardiac output measured by oesophageal Doppler ultrasonography or pulse pressure contour wave analysis.

BACKGROUND: Maintaining adequate organ perfusion during high-risk surgery requires continuous monitoring of cardiac output to optimise haemodynamics. Oesophageal Doppler Cardiac Output monitoring (DCO) is commonly used in this context, but has some limitations. Recently, the cardiac output estimated by pulse pressure analysis- (PPCO) was developed. This study evaluated the agreement of cardiac output variations estimated with 9 non-commercial algorithms of PPCO compared with those obtained with DCO. METHODS: High-risk patients undergoing neurosurgery were monitored with invasive blood pressure and DCO. For each patient, 9 PPCO algorithms and DCO were recorded before and at the peak effect for every haemodynamic challenge. RESULTS: Sixty-two subjects were enrolled; 284 events were recorded, including 134 volume expansions and 150 vasopressor boluses. Among the 9 algorithms tested, the Liljestrand-Zander model led to the smallest bias (0.03 litre min(-1) [-1.31, +1.38] (0.21 litre min(-1) [-1.13; 1.54] after volume expansion and -0.13 litre min(-1) [-1.41, 1.15] after vasopressor use). The corresponding percentage of the concordance was 91% (86% after volume expansion and 94% after vasopressor use). The other algorithms, especially those using the Winkessel concept and the area under the pressure wave, were profoundly affected by the vasopressor. CONCLUSIONS: Among the 9 PPCO algorithms examined, the Liljestrand-Zander model demonstrated the least bias and best limits of agreement, especially after vasopressor use. Using this particular algorithm in association with DCO calibration could represent a valuable option for continuous cardiac output monitoring of high risk patients. CLINICAL TRIAL REGISTRATION: Comité d'éthique de la Société de Réanimation de Langue Française No. 11-356.

Use of the Nexfin™ device to detect acute arterial pressure variations during anaesthesia induction.

BACKGROUND: Standard non-invasive arterial pressure (AP) measurements are discontinuous. By providing non-invasive beat-to-beat AP measurements, Nexfin™ might limit duration of intraoperative hypotension and hypertension. We assessed the ability of Nexfin™ to detect AP variations by comparing its trending ability with invasive AP monitoring. METHODS: Thirty-one subjects undergoing elective surgery under general anaesthesia were included. During induction, simultaneous pairs of AP measurements were collected every 5 s from the Nexfin™ finger sensor and a homolateral radial artery catheter. Magnitude and time lags of AP variations from baseline to nadir and peak were calculated for both methods. Concordance analysis was performed by the Bland-Altman method (for comparison of repeated measures when appropriate). RESULTS: Nexfin™ detected 100% of AP changes with the median delays of 0 s (-13 to 7) and 0 s (-5 to 12) for nadir and peak, respectively. Bias [limits of agreement (LOA)] of systolic AP (SAP) variations was -0.5 mm Hg (-31.2 to 30.2) and -9.4 mm Hg (-31.3 to 12.6) from baseline to nadir and from baseline to peak, respectively. For 3479 analysed paired measurements, bias was -3.8 and -8.8 mm Hg for SAP and diastolic AP, with LOA of (-36.0 to 28.5) and (-29.8 to 12.3), respectively. CONCLUSIONS: Nexfin™ detects AP variations accurately and can be a useful warning device during anaesthesia. However, it is not interchangeable with invasive monitoring, given the large LOA between the two measurements. CLINICAL TRIAL REGISTRATION: NCT01658631.

CNAP(®) does not reliably detect minimal or maximal arterial blood pressures during induction of anaesthesia and tracheal intubation.

BACKGROUND: CNAP(®) provides continuous non-invasive arterial pressure (AP) monitoring. We assessed its ability to detect minimal and maximal APs during induction of general anaesthesia and tracheal intubation. METHODS: Fifty-two patients undergoing surgery under general anaesthesia were enrolled. Invasive pressure monitoring was established at the radial artery, and CNAP monitoring using a finger sensor recording was begun before induction. Statistical analysis was conducted with the Bland-Altman method for comparison of repeated measures and intraclass correlation coefficient (ICC). RESULTS: Patients' median age was 67 years [interquartile range (59-76)], median American Society of Anesthesiologists score was 3 [interquartile range (2-3)]. Bias was 5 and -7 mmHg for peak and nadir systolic AP (SAP), with upper and lower limits of agreement of (42:-32) and (27;-42), respectively. The corresponding ICC values were 0.74 [95% confidence interval (CI) = 0.57-0.84] and 0.60 (95% CI = 0.44-0.73). Time lags to reach these values were 7.5 s (95% CI = -10.0 to 60.0) for the highest SAP and 10 s (95% CI = -12.5 to 72.5) for the lowest SAP. Bias, lower and upper limits of agreement for diastolic, and mean AP were -14 (-36 to 9) and -12 (-37 to 13) for the nadir value and -7 (-29 to 15) and -2 (-28 to 25) for the peak value. CONCLUSIONS: The CNAP monitor could detect acute change in AP within a reasonable time lag. Precision of its measurements is not satisfactory, and therefore, it could only serve as a clue to the occurrence of changes in AP.

Effect of age on the comparability of bispectral and state entropy indices during the maintenance of propofol-sufentanil anaesthesia.

BACKGROUND: Manufacturers recommend maintaining anaesthesia at a bispectral index (BIS) or state entropy (SE) index value between 40 and 60. METHODS: We prospectively studied 102 patients receiving propofol-sufentanil anaesthesia administered by anaesthetists blinded to these indices. The main endpoint was crude agreement (P(0)), defined as the proportion of agreement between BIS and SE index among three categories: <40, between 40 and 60, and >60. Discrepancies in recommendation (DR) were also considered. A DR is type 1 if BIS or SE is <40, while the other is simultaneously >60. A DR is type 2 when BIS and SE index values are on different sides of a threshold (40 or 60) with three subtypes according to the magnitude of their difference. A linear multiple regression was performed to identify covariates that are independently associated with P(0). RESULTS: In total, 12 147 pairs of values were studied. P(0) was 59.9 (24.5%) [mean (sd)]. Thirty-three patients presented more than 50% discordant pairs and only seven patients presented more than 95% concordant pairs. Type 1 DR occurred in only 1.1% of all the pairs. The median (inter-quartile range) number of type 2 DR varied from 5 (3-8) to 2 (1-3) according to the degree of difference. Multivariate analysis showed that age (P=0.0004) and electrode position (P=0.0084) were independently associated with P(0). An increase in the age of 10 yr decreases P(0) by 5%. CONCLUSIONS: The agreement between BIS and SE indices is moderate and deteriorates as patients' age increases. This study cannot determine which index is best adapted for elderly patients. Additional work comparing both indices with raw EEG traces is warranted.

Unusual arterial thrombotic events in Covid-19 patients.

INTRODUCTION: COVID-19 infection is commonly complicated with pro-thrombotic state and endothelial dysfunction. While several studies reported a high incidence of venous thromboembolic events. The occurrence of arterial thromboses are yet rarely described and could be underestimated. OBJECTIVES: To describe the clinical and biological characteristics of COVID-19 patients presenting with an associated arterial thromboembolic event. MATERIAL AND METHODS: We performed a retrospective multicentric study in 3 centers between France and Italy. All patients with a confirmed SARS-CoV-2 infection and arterial thromboembolic events were included in the analysis. RESULTS: From March 8th to April 25th 2020, we identified 20 patients (24 events) with arterial thromboembolic events over 209 admitted patients (9.6%) with severe COVID-19 infection. Arterial thrombotic events included acute coronary occlusions (n = 9), stroke (n = 6), limb ischemia (n = 3), splenic infarcts (n = 3), aortic thrombosis (n = 2) and occlusive mesenteric ischemia (n = 1). At the time of the event, 10/20 (50%) of patients received thromboprohylaxis, 2/20 (10%) were receiving treatment dose anticoagulation and 5/20 (25%) were receiving antiplatelet therapy. CONCLUSION: Our observations suggest that serious arterial thrombotic events might occur in Covid-19 patients. However, the exact incidence of such events and the best way to prevent them yet remains to be investigated.

Impact of a high-dose nitrate strategy on cardiac stress in acute heart failure: a pilot study.

BACKGROUND: Intravenous nitrate therapy has been shown to improve short-term outcome of acute heart failure patients treated in the intensive care unit. The potential of a noninvasive high-dose nitrate strategy in the Emergency Department and the general ward remains unknown. METHODS: A total of 128 consecutive acute heart failure patients were either treated with standard therapy or high-dose sublingual and transdermal nitrates on top of standard of care treatment. Cardiac recovery, quantified by B-type natriuretic peptide (BNP) levels during the first 48 h, was the primary endpoint. Secondary endpoints ascertained the safety of the nitrate therapy. RESULTS: The high nitrate group received higher doses of nitrates during the first 48 h compared to the standard therapy group [82.4 mg (46.2-120.6) vs. 20 mg (10-30) respectively, P < 0.001]. The amount of diuretics given in both groups was similar. BNP levels decreased in all patients (P < 0.0001). However, the BNP decrease was larger in the high-dose nitrate group (P < 0.0001). The larger decrease in BNP in the high-dose nitrate group was already apparent 12 h after the initiation of treatment. After 48 h BNP values decreased by an average of 29 +/- 4.9% in the high-dose nitrate strategy group compared to 15 +/- 5.4% during standard therapy. There was a strong trend towards fewer ICU admissions in the high-dose nitrate group [high-dose nitrates: 2 cases (4%) vs. standard therapy: 9 cases (13%); P = 0.06]. During the study period, no intergroup changes were observed in blood pressure, RIFLE classes of acute kidney injury or troponin T. In-hospital and 90-day outcome was similar amongst the two groups. CONCLUSIONS: A noninvasive high-dose nitrate strategy on top of standard therapy is safe and notably accelerates cardiac recovery in patients observed on the general ward.

Correlation between uteroplacental three-dimensional power Doppler indices and true uterine blood flow: evaluation in a pregnant sheep model.

OBJECTIVES: Three-dimensional (3D) Doppler quantification within the uteroplacental unit could be of great help in understanding and screening for pre-eclampsia and intrauterine growth restriction. Yet the correlation between 3D Doppler indices and true blood flow has not been confirmed in vivo. The aim of this study was to evaluate this correlation in a pregnant sheep model. METHODS: A blood flow quantitative sensor and a controllable vascular occlusion system were placed around the common uterine artery in seven sheep in late pregnancy, while all the other arterial supplies were ligated. Several occlusion levels were applied, from 0 to 100%, simultaneously with 3D Doppler acquisitions of several placentomes, using standardized settings. Each placentome was analyzed using VOCAL™ (Virtual Organ Computer-aided AnaLysis) software. The correlation between true blood flow and Doppler indices (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) was evaluated, together with measurement reproducibility. RESULTS: Forty-eight acquisitions were analyzed. All 3D Doppler indices were significantly correlated with true blood flow. Higher correlations were observed for VI and VFI (r = 0.81 (0.74-0.87), P < 0.0001 and r = 0.75 (0.67-0.82), P < 0.0001) compared with FI (r = 0.53 (0.38-0.64) P < 0.0001). Both intra- and interobserver reproducibility were high, with intraclass correlation coefficients of at least 0.799. CONCLUSION: This is the first in-vivo experimental study confirming a significant correlation between true blood perfusion and quantitative 3D Doppler indices measured within the uteroplacental unit. These results confirm the potential usefulness of 3D Doppler ultrasound for the assessment of placental vascular insufficiency both in clinical cases and in a research setting.

Radiofrequency ablation of retained placenta accreta after conservative management: preliminary evaluation in the pregnant ewe and in normal human placenta in vitro.

OBJECTIVE: To evaluate radiofrequency (RF) efficiency and safety for the ablation of retained placenta in humans, using a pregnant sheep model. DESIGN: Experimental study. SETTING: Laboratory of Surgery School, Nancy, France. POPULATION/SAMPLE: Three pregnant ewes/ten human placentas. METHODS: Various RF procedures were tested in pregnant ewes on 50 placentomes (individual placental units). Reproducibility of the best procedure was then evaluated in a further 20 placentomes and on ten human term placentas in vitro after delivery. MAIN OUTCOME MEASURES: Placental tissues destruction, lesions' size, myometrial lesions. RESULTS: Low power (100 W) and low target temperatures (60 degrees C) lead to homogenous tissue destruction, without myometrial lesion. No significant difference was observed in terms of lesion size and procedure duration for in the placentomes of pregnant ewe in vivo and in human placentas in vitro. The diameter of the ablation could be correlated with the tines deployment. CONCLUSION: The placental tissue structure is very permissive to RF energy, which suggests that RF could be used for the ablation of retained placenta, providing optimal control of tissue destruction. These results call for further experimental evaluations.

[Complete cost of surgery for postpartum haemorrhage]. / Coût total des actes chirurgicaux dans la prise en charge des hémorragies de la délivrance.

OBJECTIVE: Reduction of maternal mortality is a major priority in the public health domain. One of the main causes of maternal mortality is postpartum haemorrhage. Because economic pressures favour the use of less expensive strategies, it is becoming now critical to know exactly the cost of the surgical procedures involved in the treatment of postpartum haemorrhage, in order to provide future guidelines in Implementing reforms in hospital. MATERIALS AND METHODS: Evaluation was made on multiple data collected in the Gynecology-Obstetrics and Central Sterile Supplies departments of a tertiary care Hospital. Analysis of the production costs was made based on the actual costs. The receipts were figured on the basis of applicable reimbursement in France in 2005, taking into account the financial decisions of the producers. RESULTS: From January 2004 to December 2005, 262 patients were treated for postpartum hemorrhage and patients files were available for review in 255 cases. Of these, surgery was performed in 52 cases. The costs of surgery in the postpartum care ranged from 275.04 euro per manual exploration of the uterine cavity (n=8), 302.48 euro per exploration with valve (n=26), 601.55 euro per vascular ligation (n=3), 725.53 euro per vaginal packing or unpacking (n=10) to 875.06 euro per hysterectomy (n=5). Cleaning and sterilizing of surgical instruments represented a substantial burden, ranging from 7.5% to 11.4% of the total cost of surgery. DISCUSSION AND CONCLUSION: The costs of surgery for postpartum haemorrhage have been calculated to provide future guidelines for the directions and follow-up of these activities in light of the T2A-EPRD and poles of activity. The actual costs could be used to determine the bases of one or more French DRGs (PMSI) "postpartum hemorrhage" evolution.

Cough reflex sensitivity after elective Caesarean section under spinal anaesthesia and after vaginal delivery.

BACKGROUND: In pregnancy, airway oedema and heartburn may increase cough sensitivity, whereas spinal anaesthesia (SA) with local anaesthetics and opiates may decrease it. Decreased cough sensitivity increases the risk for pneumonia or retained secretions. The aim of this study was to determine whether cough sensitivity is increased in pregnant patients and if it is decreased after planned Caesarean section (CS) under SA. METHODS: Twenty-seven non-pregnant volunteers, 27 patients after vaginal delivery (VD group), and 28 patients after CS under SA (CS group) were studied. For SA, hyperbaric bupivacaine 8-12 mg, sufentanil 5 microg, and morphine 100 microg was given. Increasing concentrations of nebulized citric acid were delivered until eliciting cough. The concentration eliciting one (C1) and two coughs (C2) were recorded and log transformed for analysis (log C1 and log C2). RESULTS: Median (inter-quartile) log C1 was 1.3 (0.6) mg ml(-1) in the VD group, 1.6 (0.6) mg ml(-1) in the non-pregnant group (P < 0.01 vs VD group), and 2.2 (0.7) mg ml(-1) in the CS group (P < 0.0001 and P < 0.01 vs VD and non-pregnant groups, respectively). Similar results were observed with log C2. In CS group, log C1 and log C2 remained increased up to 4 h after SA. CONCLUSIONS: Cough sensitivity was increased after VD but decreased for up to 4 h after SA.

Skin conductance as a pain assessment tool during chest tube removal: An observational study.

BACKGROUND: Skin conductance variability to assess pain has shown varying results. Skin conductance responses per second (SCR) during a standardized painful stimulus in awake adults may give further understanding of the method's validity. The purpose of this study was to validate the SCR with the visual analogue scale (VAS) for pain (P-VAS) and anxiety (A-VAS) during chest tube removal (CTR). METHODS: Ninety-five patients receiving epidural or non-epidural treatment, scheduled for CTR, were studied. Pain or anxiety was considered when VAS > 30 mm; the SCR cut-off value reflecting pain was ≥0.2 SCR. RESULTS: SCR values could not be recorded in eight cases before CTR, six cases during CTR and seven cases after CTR. CTR induced increases in SCR, P-VAS and A-VAS (p < 0.001). Seventy-seven percent of all pairs of P-VAS and SCR values were well-classified; P-VAS ≤ 30 mm and SCR < 0.2 or P-VAS > 30 mm and SCR ≥ 0.2. SCR obtained before CTR differentiates between patients with and without pain during CTR in all patients (p = 0.04) and in the subgroup of non-anxious patients (p = 0.02), but not in the subgroup of anxious patients. SCR obtained during CTR had similar values in patients with and without pain in all patients and in the subgroup of anxious patients, but in the subgroup of non-anxious patients SCR during CTR differentiates patients with and without pain (p = 0.009). CONCLUSIONS: SCR increases during painful procedures. Preprocedural SCR may help predict reported pain in patients exposed to painful procedures. SCR during CTR differentiates between patients with and without pain only in non-anxious patients. SIGNIFICANCE: Preprocedural SCR may help predict reported pain in patients exposed to painful procedures. Procedural SCR accuracy improves in a subgroup of non-anxious patients. P-VAS is influenced by anxiety different from SCR.

Decongestive effects of levosimendan in cardiogenic shock induced by postpartum cardiomyopathy.

BACKGROUND: Catecholamines and/or levosimendan have been proposed for haemodynamic restoration during cardiogenic shock (CS). In CS induced by post-partum cardiomyopathy (PPCM), levosimendan might be particularly favourable. The aim of this study was to evaluate the haemodynamic and echocardiographic effects of levosimendan in patients with CS, in particular in patients with PPCM-induced CS. METHODS: Twenty-eight patients with refractory CS were retrospectively included in the study. Among them, a cohort of 8 women with PPCM-induced CS was included. All patients were treated with levosimendan (loading dose followed by a continuous infusion for 24 h) and were invasively monitored, including a pulmonary artery catheter, for 48hours. Echocardiographic measurements were performed at baseline and during follow-up. RESULTS: Significant improvements in haemodynamic parameters were observed 48 h after starting levosimendan. The cardiac index increased (+1.2±0.6L/min, P<0.001) and filling pressures decreased (pulmonary artery occlusion pressure, PAOP: -11.2±4.3mmHg, P<0.001; right-atrial pressure, RAP: -6.1±4.9mmHg, P<0.001). The left ventricular ejection fraction was significantly higher at 48 h compared to baseline (38% [34-46%] versus 27% [22-30%], P<0.001). Despite similar characteristics at baseline, in the subgroup of patients with PPCM, more profound decongestive effects at 48hours were observed: PAOP (13±2 versus 17±4mmHg, P=0.007) and RAP (12±4 versus 17±4mmHg, P=0.006) were significantly lower in the PPCM subgroup compared to the non-PPCM subgroup. CONCLUSIONS: Haemodynamics and left-ventricular ejection fraction rapidly improved after treatment with levosimendan. In patients with PPCM-induced CS, a more profound reduction of congestion was observed.

Epidural analgesia combined with a comprehensive physiotherapy program after Cytoreductive Surgery and HIPEC is associated with enhanced post-operative recovery and reduces intensive care unit stay: A retrospective study of 124 patients.

BACKGROUND: Although Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) confers health benefits in peritoneal carcinomatosis (PC) treatment, it is associated with significant postoperative morbidity and mortality rate with increased length of hospital stay. The goal of this study is to determine whether a new comprehensive physiotherapy program including epidural loco-regional analgesia can improve the quality of care and patients recovery. METHODS: Between 2009 and 2013, 124 patients with PC were operated for CRS and HIPEC procedures. These patients were analyzed and divided in 2 groups by means of time. No Physio group included patients operated from 2009 to 2011 (n = 57) having a thoracic patient controlled epidural analgesia (PCEA) but no preoperative physiotherapy program. The Physio group included patients operated from 2012 to 2013 (n = 67) having both a PCEA with a preoperative physiotherapy program. RESULTS: The mortality rate was 1.6% (n = 2). The median length of stay in the intensive care unit (ICU) was lower in the Physio group, 2 days vs. 0 for No Physio group (p < 0.0001). The first time of mobilization after surgery was shorter in the Physio group (day 3 vs. 2, p = 0.0043). The overall satisfaction in the Physio group was achieved in 93% of patients, helping in decreasing fear of surgery and mobilization in 70% and 84% of cases respectively. CONCLUSION: Our study demonstrates that a clear pre-operative information and education by a physiotherapist, associated with a PCEA-pain management significantly benefits the patient's post-operative recovery and reduces the length of stay in the ICU.