Evaluation of the Duration of Preanesthesia Consultation: Prospective and Multicenter Study.

BACKGROUND: The time allocated to the preanesthesia consultation (PAC) of a patient undergoing an elective surgical procedure is an important factor to optimize consultation sessions. The main objective of this study was to build a model predictive of the duration of the PAC. METHODS: We prospectively studied 1007 patients undergoing a PAC from January 2016 to June 2018 in 4 different hospitals. A general linear model was fitted to predict the overall duration of the PAC. Secondary models predicted the time spent on clinical evaluation and the time assigned to delivering information. RESULTS: After exclusion of 40 patients with major data inconsistencies, the mean (standard deviation [SD]) overall duration of the PAC was 11.2 (5.8) minutes, split into 6.8 (4.1) minutes of information and 4.4 (2.7) minutes of clinical evaluation. It was, respectively, 11.4 (5.9), 6.9 (4.2), and 4.4 (2.7) in the 924 patients ≥16 years of age and, respectively, 8.3 (2.3), 4.3 (1.8), and 4.1 (1.8) in 43 children. The American Society of Anesthesiologists (ASA) score, the number of comorbidities or treatment, surgery discipline, and context (ambulatory, conventional hospitalization, and intensive care unit) were significantly correlated to PAC time. In the 924 adult patients, the models had an R2 adjusted for overfitting at 0.47 for the total duration of PAC, 0.45 for the clinical examination time, and 0.24 for the information time. The estimated residual standard deviations were, respectively, 4.3, 3.1, and 2.7 minutes. CONCLUSIONS: The predictive performances of the model explaining the overall duration of PAC were average (R2 = 0.47) and should be confirmed by further studies to use it for optimizing the organization of the consultation by individualizing the time dedicated to each consultation.

Preoperative analgesic instruction and prescription reduces early home pain after outpatient surgery: a randomized controlled trial.

BACKGROUND: Home pain remains the most common complication in outpatient surgery. Optimal management requires good information and early availability of analgesics. The main objective of this randomized controlled trial was to compare the effects of pre- vs postoperative analgesic instruction and prescription on postoperative home pain. METHODS: Patients were randomized into an anesthesia consultation group (AC group) and a standard postoperative group (POP group). The AC group and the POP group received analgesic prescription and instruction during the anesthesia consultation and after surgery, respectively. The primary outcome was the incidence of home pain on postopertive day one (D1). Home pain was defined by at least one episode with a numeric rating scale score > 3/10 at rest. Treatment compliance and postoperative nausea and vomiting (PONV) were also assessed on D1 and postoperative day 7 (D7). RESULTS: One hundred and eighty-six patients were included between May 2017 and May 2018 at Rouen University Hospital, France. Ninety-four patients were randomized to the AC group and 92 to the POP group. On D1, the incidence of pain was 23/94 (24%) in the AC group and 44/92 (48%) in the POP group (P < 0.001). On D1, the rate of treatment compliance was significantly higher in the AC group than in the POP group (85% vs 69%; P = 0.02). There was no statistically significant difference in the incidence of pain or treatment compliance between groups on D7 or in PONV on D1 and on D7. CONCLUSIONS: Preoperative analgesic instruction and prescription during anesthesia consultation reduces the incidence of early postoperative home pain in outpatient surgery. TRIAL REGISTRATION: www.clinicaltrialsgov (NCT03205189); registered 2 July 2017.

RéSUMé: CONTEXTE: La douleur à la maison demeure la complication la plus fréquente après une chirurgie ambulatoire. Une prise en charge optimale nécessite de bonnes informations et la disponibilité précoce d'analgésiques. L'objectif principal de cette étude randomisée contrôlée était de comparer les effets d'instructions et d'une prescription pré- vs postopératoires d'analgésiques sur la douleur postopératoire à la maison. MéTHODE: Les patients ont été randomisés dans un groupe de consultation pré-anesthésique (groupe pré) et un groupe postopératoire standard (groupe post). Le groupe pré et le groupe post ont reçu une prescription d'analgésiques ainsi que les instructions s'y rattachant pendant la consultation en anesthésie préopératoire et après la chirurgie, respectivement. Le critère d'évaluation principal était l'incidence de douleur à la maison au premier jour postopératoire (post-op 1). La douleur à domicile était définie par un épisode de douleur ou plus avec un score > 3/10 au repos sur l'échelle d'évaluation numérique. L'observance du traitement et les nausées et vomissements postopératoires (NVPO) ont également été évalués les jours post-op 1 et 7. RéSULTATS: Cent quatre-vingt-six patients ont été inclus entre mai 2017 et mai 2018 au Centre hospitalier universitaire de Rouen. Quatre-vingt-quatorze patients ont été randomisés au groupe pré et 92 au groupe post. Au jour post-op 1, l'incidence de la douleur était de 23/94 (24 %) dans le groupe pré et de 44/92 (48 %) dans le groupe post (P < 0,001). Au jour post-op 1, le taux d'observance du traitement était significativement plus élevé dans le groupe pré que dans le groupe post (85 % vs 69 %; P = 0,02). Il n'y avait aucune différence statistiquement significative dans l'incidence de douleur ou d'observance du traitement entre les groupes au jour post-op 7 ou dans les NVPO aux jours post-op 1 et 7. CONCLUSION: L'instruction et la prescription préopératoires d'analgésiques pendant la consultation anesthésique préopératoire réduisent l'incidence de la douleur postopératoire précoce à domicile en chirurgie ambulatoire. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03205189); enregistrée le 2 juillet 2017.

Anticoagulation Monitoring with Activated Partial ThromboPlastin Time and Anti-Xa Activity in Intensive Care Unit Patients: Interest of Thrombin Generation Assay.

Current guidelines recommend monitoring the anticoagulant effect of unfractionated heparin (UFH) by measuring anti-Xa activity rather than activated partial thromboplastin time (aPTT) in intensive care unit (ICU) patients. The primary objective of this study was to evaluate the correlation of aPTT, anti-Xa activity, and thrombin generation in UFH-treated ICU patients. A prospective observational pilot study was conducted in adult surgical ICU patients treated with UFH. aPTT and anti-Xa activity were monitored daily. The therapeutic target was aPTT between 50 s and 84 s, and/or anti-Xa between 0.3 and 0.7 U/mL. Correlation among aPTT, anti-Xa activity, and thrombin generation was determined by measuring endogenous thrombin potential (ETP), with the inflammatory response evaluated. C-reactive protein (CRP) was used as a marker of inflammatory response. The plasma of 107 samples from 30 ICU patients was analyzed. The correlation between aPTT and anti-Xa activity was 0.66, CI95% [0.54;0.76] (p < 0.0001). Although thrombin generation, aPTT, and anti-Xa were correlated with inflammatory responses, the correlation was higher with thrombin generation and anti-Xa activity compared to aPTT. When aPTT was in a therapeutic range, a low thrombin generation was observed but was 50% inhibited when anti-Xa was in a therapeutic range. Coagulation testing with aPTT, anti-Xa correlated with thrombin generation. A 50% decrease in thrombin generation was observed when anti-Xa was within a therapeutic range. Further work is needed to evaluate coagulation biomarker responses and clinical outcomes in specific ICU populations.

Postoperative hunger after outpatient surgery in patients anesthetized with propofol vs sevoflurane: a randomized-controlled trial.

PURPOSE: Previous preclinical and preliminary clinical data suggest an appetite-stimulating effect of propofol compared with halogenated drugs. This study compared the effects of propofol with those of sevoflurane on recovery of hunger during the postoperative period. METHODS: Patients undergoing outpatient transvaginal oocyte retrieval were randomized to propofol-remifentanil (propofol group) or sevoflurane-remifentanil (sevoflurane group) anesthesia. The primary endpoint was the time before feeling hungry (≥ 50/100 mm on a visual analogue scale). Secondary endpoints included plasma levels of ghrelin, leptin, and insulin (ten minutes, one hour, and two hours after anesthesia), caloric intake at first feed, and discharge readiness time. RESULTS: In the 58 patients allocated to either the propofol or sevoflurane group, there was no difference in the median [interquartile range] recovery time of hunger (97 [75-138] vs 97 [80-140] min, respectively; median difference, 1; 95% confidence interval [CI], - 15 to 14; P = 0.91); caloric intake (245 [200-343] vs 260 [171-314] kcal; P = 0.39); or discharge readiness time (125 [85-153] vs 125 [95-174] min, P = 0.29). The groups showed no difference in crude plasma levels of ghrelin, leptin, and insulin at any time-point. When peptide plasma levels were expressed as a % change from baseline, there was a higher insulin plasma level one hour after anesthesia in the sevoflurane group (median difference, 4.9%; 95% CI, - 16.2 to 43.4) compared with the propofol group (median difference, - 21.2%; 95% CI, - 35.7 to 9.1; adjusted P = 0.01). CONCLUSION: Propofol did not accelerate the recovery of hunger compared with sevoflurane after outpatient minor surgery. Moreover, propofol did not have distinguishable effects on other clinical or biological parameters associated with food intake. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT02272166); registered 22 October, 2014.

RéSUMé: OBJECTIF: Des données précliniques et cliniques préliminaires suggèrent un effet de stimulation de l'appétit du propofol par rapport aux gaz halogénés. Cette étude a comparé les effets du propofol à ceux du sévoflurane sur le rétablissement de la faim en période postopératoire. MéTHODE: Des patientes subissant un prélèvement des ovocytes par voie transvaginale ont été randomisées à recevoir une anesthésie à base de propofol et rémifentanil (groupe propofol) ou de sévoflurane et rémifentanil (groupe sévoflurane). Le critère d'évaluation principal était la période de temps avant de ressentir de la faim (≥ 50/100 mm sur une échelle visuelle analogique). Les critères d'évaluation secondaires comprenaient les taux plasmatiques de ghréline, de leptine et d'insuline (à dix minutes, une heure et deux heures après l'anesthésie), l'apport calorique lors du premier repas, et le moment où les patientes étaient prêtes à recevoir leur congé. RéSULTATS: Chez les 58 patientes allouées aux groupes propofol ou sévoflurane, aucune différence n'a été observée dans le temps médian [écart interquartile (ÉIQ)] jusqu'à retour de la faim (97 [75­138] vs 97 [80­140] min, respectivement; différence médiane, 1; intervalle de confiance [IC] 95 %, − 15 à 14; P = 0,91), ni dans l'apport calorique (245 [200­343] vs 260 [171­314] kcal; P = 0,39) ou le moment où elles étaient prêtes à recevoir leur congé (125 [85-153] vs 125 [95-174] min, P = 0,29). Les groupes n'ont démontré aucune différence en matière de taux plasmatiques de ghréline, de leptine et d'insuline à quelque point dans le temps que ce soit. Lorsque les taux plasmatiques de peptides étaient exprimés en % de changement par rapport aux taux de base, on a observé un taux plasmatique plus élevé d'insuline une heure après l'anesthésie dans le groupe sévoflurane (différence médiane, 4,9 %; IC 95 %, − 16,2 à 43,4) par rapport au groupe propofol (différence médiane, − 21,2 %, IC 95 %, − 35,7 à 9,1; P ajusté = 0,01). CONCLUSION: Le propofol n'a pas accéléré le retour de la faim par rapport au sévoflurane après une chirurgie ambulatoire mineure. De plus, le propofol n'a pas démontré d'effets distinctifs sur d'autres paramètres cliniques ou biologiques associés à l'ingestion de nourriture. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT02272166); enregistrée le 22 octobre 2014.

Ketamine and Etomidate Down-regulate the Hypothalamic-Pituitary-Adrenal Axis in an Endotoxemic Mouse Model.

BACKGROUND: We compared the effects of etomidate and ketamine on the hypothalamic-pituitary-adrenal axis during sepsis. METHODS: Mice (n = 5/group) were injected intraperitoneally with lipopolysaccharide (10 mg/kg) and 6 h later randomized to receive ketamine (100 mg/kg), etomidate (30 mg/kg), or saline. At two time points (12 and 48 h), messenger RNA levels of hypothalamic corticotropin-releasing hormone, pituitary proopiomelanocortin, and four adrenal enzymes (P450 side-chain cleavage, 3ß-hydroxysteroid deshydrogenase, 21-hydroxylase, and 11ß-hydroxylase) were measured by in situ hybridization (results are presented as optical density), and plasma levels of corticosterone and adrenocorticotropin hormones were measured by enzyme-linked immunosorbent assay (mean ± SD). RESULTS: At 12 h, lipopolysaccharide induced an overexpression of corticotropin-releasing hormone (32 ± 5 vs. 18 ± 6, P < 0.01), proopiomelanocortin (21 ± 3 vs. 8 ± 0.9, P < 0.0001), P450 side-chain cleavage (32 ± 4 vs. 23 ± 10, P < 0.05), 21-hydroxylase (17 ± 5 vs. 12 ± 2, P < 0.05), and 11ß-hydroxylase (11 ± 4 vs. 6 ± 0.5, P = 0.001), and an elevation of corticosterone (642 ± 165 vs. 98.3 ± 63 ng/ml, P < 0.0001). Etomidate and ketamine reduced P450 side-chain cleavage (19 ± 7 and 19 ± 3 vs. 32 ± 4, P < 0.01), 21-hydroxylase (8 ± 0.8 and 8 ± 1 vs. 17 ± 5, P < 0.001), 11ß-hydroxylase (4 ± 0.5 and 7 ± 1 vs. 11 ± 4, P < 0.001 and P < 0.05), and corticosterone (413 ± 189 and 260 ± 161 vs. 642 ± 165 ng/ml, P < 0.05 and P < 0.01). Ketamine also inhibited adrenocorticotropin hormone production (2.5 ± 3.6 vs. 36 ± 15 pg/ml, P < 0.05). At 48 h, all four adrenal enzymes were down-regulated by lipopolysaccharide administration with corticosterone levels similar to the control group. Ketamine and etomidate did not modify corticosterone plasma levels. CONCLUSIONS: Our endotoxemic model induces an initial activation of the hypothalamic-pituitary-adrenal axis, followed by a secondary inhibition of adrenal steroidogenesis processes. Ketamine and etomidate inhibit the enzyme expression and activity of the adrenal gland at the early stage.

Background noise lowers the performance of anaesthesiology residents' clinical reasoning when measured by script concordance: A randomised crossover volunteer study.

BACKGROUND: Noise, which is omnipresent in operating rooms and ICUs, may have a negative impact not only patients but also on the concentration of and communication between clinical staff. OBJECTIVE: The present study attempted to evaluate the impact of noise on the performance of anaesthesiology residents' clinical reasoning. Changes in clinical reasoning were measured by script concordance tests (SCTs). DESIGN: This was a randomised and crossover study. SETTING: Single centre at Rouen University Hospital in April 2014. POPULATION: All year 1 to 4 residents enrolled in the anaesthesiology training programme were included. INTERVENTION: Performance was assessed using a 56-item SCT. Two resident groups were formed, and each was exposed to both quiet and noisy atmospheres during SCT assessment. Group A did the first part of the assessment (28 SCT) in a quiet atmosphere and the second part (28 SCT) in a noisy atmosphere. Group B did the same in reverse order. MAIN OUTCOME MEASURES: The primary outcome of this study was residents' performance as measured by SCT, with and without noise (mean of 100 points 95% confidence interval). RESULTS: Forty-two residents were included. Residents' performance, measured by SCT, was weaker in a noisy environment than in a quiet environment [59.0 (56.0 to 62.0) vs 62.8 (60.8 to 64.9), P = 0.04]. This difference lessened as medical training advanced, as this difference in performance in noisy vs quiet environments was not observed in year 3 and 4 residents [62.9 (59.2 to 66.5) vs 64.0 (61.9 to 66.1), P = 0.60], whereas it was higher for year 1 and 2 residents [54.8 (50.6 to 59.1) vs 61.5 (57.9 to 65.1), P = 0.02]. CONCLUSION: Our study suggests that noise affects clinical reasoning of anaesthesiology residents especially junior residents when measured by SCT. This observation supports the hypothesis that noise should be prevented in operating rooms especially when junior residents are providing care.

Increased plasma levels of endozepines, endogenous ligands of benzodiazepine receptors, during systemic inflammation: a prospective observational study.

INTRODUCTION: Recent work has shown that benzodiazepines interact with the immune system and exhibit anti-inflammatory effects. By using in vitro models, researchers in several studies have shown that the peptidergic endogenous ligands of benzodiazepine receptors, named endozepines, are involved in the immune response. All endozepines identified so far derive from diazepam-binding inhibitor (DBI), which generates several biologically active fragments. The aim of the present study was to measure plasma levels of DBI-like immunoreactivity (DBI-LI) in a rat model of sepsis and in patients with systemic inflammation from septic or non-septic origin. METHODS: Cecal ligation and puncture (CLP) or sham surgery was performed in rats. Blood samples were taken from animals, patients hospitalized for digestive surgery with inflammatory diseases, and healthy volunteers. Measurements of plasma DBI-related peptides were carried out by radioimmunoassay in animal and human samples. RESULTS: In the rats, CLP provoked an increase of plasma DBI-LI (+37%) 6 hours postsurgery. In humans, DBI-LI levels were significantly higher in the systemic inflammation group than in the healthy volunteer group (48.6 (32.7 to 77.7) pg/ml versus 11.1 (5.9 to 35.3) pg/ml, P < .001). We found a positive correlation between endozepine levels and Acute Physiology and Chronic Health Evaluation II score (r s = 0.33 (0.026 to 0.58), P < 0.05) and tumor necrosis factor α levels (r s = 0.43 (0.14 to 0.65), P < 0.01). The area under the receiver operating characteristic curve for endozepines was 0.842 (95% CI (0.717 to 0.966), P < 0.0001) for discriminating patients with inflammation from healthy volunteers. CONCLUSIONS: Endozepines might be involved in the inflammatory response in patients with systemic inflammation.

The antiapoptotic effect of remifentanil on the immature mouse brain: an ex vivo study.

BACKGROUND: The use of remifentanil in a context of potential prematurity led us to explore ex vivo the opioid effects on the immature mouse brain. Remifentanil enhances medullary glutamatergic N-methyl-D-aspartate (NMDA) receptor activity. Furthermore, in neonatal mouse cortex, NMDA was previously shown to exert either excitotoxic or antiapoptotic effects depending on the cortical layers. With the use of a model of acute cultured brain slices, we evaluated the potential necrotic and apoptotic effects of remifentanil, alone or associated with its glycine vehicle (commercial preparation of remifentanil, C.P. remifentanil), on the immature brain. METHODS: Cerebral slices from postnatal day 2 mice were treated up to 5 hours with the different compounds, incubated alone or in the presence of NMDA. The necrotic effect was studied by measuring lactate dehydrogenase activity and 7-Aminoactinomycin D labeling. Apoptotic death was evaluated by measurement of caspase-3 activity and cleaved caspase-3 protein levels, using Western blot and immunohistochemistry. Extrinsic and intrinsic apoptotic pathways were investigated by measuring caspase-8, caspase-9 activities, Bax protein levels, and mitochondrial integrity. RESULTS: C.P. remifentanil was ineffective on necrotic death, whereas it significantly reduced caspase-3 activity and cortical cleaved caspase-3 levels. C.P. remifentanil inhibited cortical Bax protein expression, caspase-9 activity, and preserved mitochondrial integrity, whereas it had no effect on caspase-8 activity. Its action targeted the neocortex superficial layers, and it was reversed by the opioid receptors antagonist naloxone and the NMDA antagonist MK801. Remifentanil and glycine acted synergistically to inhibit apoptotic death. In addition, C.P. remifentanil enhanced the antiapoptotic effect of NMDA, whereas it did not improve NMDA excitotoxicity in brain slices. CONCLUSION: The present data indicate that at a supraclinical concentration C.P. remifentanil had no pronecrotic effect but exerted ex vivo antiapoptotic action on the immature mouse brain, involving the opioid and NMDA receptors, and the mitochondrial-dependent apoptotic pathway. Assessment of the impact of the antiapoptotic effect of remifentanil in in vivo neonatal mouse models of brain injury will also be essential to measure its consequences on the developing brain.

Comparison of Two Dexmedetomidine Administration Strategies on the Incidence of Postoperative Respiratory Complications: A Retrospective, Inverse Probability of Treatment Weighted Study.

Randomized controlled trials have shown a higher risk of postoperative hypoxemia and delayed extubation with opioid-free anesthesia (OFA), compared with opioid anesthesia. The practice of OFA is not standardized. The objective of this study is to investigate the association between the dexmedetomidine administration protocol used and the occurrence of postoperative respiratory complications. This work is a retrospective, propensity score-adjusted study (inverse probability of treatment weighting) conducted between January 2019 and September 2021 in a French tertiary care university hospital, including 180 adult patients undergoing major digestive surgery. Comparison of 2 anesthesia protocols: with a continuous intravenous maintenance dose of dexmedetomidine following a bolus (group B+M, n = 105) or with a bolus dose alone (group B, n = 75). The main outcome measure was a composite respiratory end point within 24 hours of surgery. There was no significant difference in the incidence of overall respiratory complications, as assessed by the primary end point. Nevertheless, there were more patients with postoperative hypercapnia in group B+M than in group B (16% vs 2.5%, P = .004). Patients in group B+M were extubated later than patients in group B (group B+M, median 40 minutes, IQR 20-74 minutes; group B, median 20 minutes, IQR 10-50 minutes; P = .004). Our study showed negative results for the primary end point. However, data on the increased risk of postoperative hypercapnia in patients receiving a maintenance dose of dexmedetomidine are new. Other prospective randomized studies with greater power are necessary to confirm these data and to make OFA safer, by reducing the prescribed doses of dexmedetomidine.

Early detection of gut ischemia-reperfusion injury during aortic abdominal aneurysmectomy: a pilot, observational study.

OBJECTIVE: D-lactate is the enantiomer of L-lactate, which is measured routinely in clinical practice to assess cell hypoxia. D-lactate has been proposed as a specific marker of gut ischemia-reperfusion (IR), particularly during surgery for ruptured abdominal aortic aneurysms. The aim of this study was to compare the use of D-lactate measurement and colonic tonometry (taken as a reference method) for gut IR detection during elective infrarenal aortic aneurysm (IrAA) surgery. DESIGN: Prospective, monocenter, observational study. SETTING: Vascular surgery unit, university hospital. PARTICIPANTS: Candidates for elective IrAA surgery. INTERVENTIONS: Patients without (controls) and with gut IR (defined as ΔCO2>2.6 kPa) were compared retrospectively. MEASUREMENT AND MAIN RESULTS: D-lactate levels were compared with colonic perfusion levels (ΔCO2), as assessed by colonic tonometry, at 7 time points during surgery and until 24 hours after surgery. D-lactate also was measured in mesenteric vein blood before and after gut reperfusion. Plasma TNF-α level was measured at the same time points to assess systemic inflammatory response. Eighteen patients requiring elective IrAA surgery were included. The ΔCO2 and TNF-α level varied significantly over time. There was a significant ΔCO2 peak at the end of clamping (2.6±1.8 kPa, p = 0.006) and a significant peak in TNF-α level after 1 hour of reperfusion (183±53 ng/L, p = 0.05). D-lactate levels were undetectable in systemic and mesenteric blood in all the patients throughout the study period. Gut IR patients (n = 6) experienced a longer overall duration of intraoperative hypotensive episodes and received more catecholamines than the controls (n = 12). CONCLUSIONS: Compared with colonic tonometry, D-lactate was not a reliable biomarker of gut IR during elective IrAA surgery.

Intraoperative factors affecting renal outcome after open repair of suprarenal aortic aneurysms.

BACKGROUND: The open repair of suprarenal aortic aneurysm requires supraceliac aortic cross-clamping and separate renal artery reconstruction. The aim of this study was to determine the intraoperative factors responsible for postoperative renal dysfunction. METHODS: Between January 1, 2000 and May 31, 2010, 54 suprarenal aortic aneurysms were repaired at our center (mean age of the patients, 66 ± 8 years). All cases were operated through a left retroperitoneal approach without left renal vein division. Acute kidney injury was defined as a 50% increase of serum creatinine level from the preoperative baseline concentration. Perioperative variables were tested to be correlated with renal dysfunction (Spearman rank). RESULTS: The ischemic time was 28 ± 8 minutes for the mesentery and the right kidney and 63 ± 16 minutes for the left kidney. The total aortic clamping time was 115 ± 27 minutes. The volume of autologous transfusion was 957 ± 479 mL, allogeneic transfusion was 936 ± 473 mL, and colloids and crystalloids was 7,194 ± 2,201 mL. Two patients died. Acute kidney injury occurred in 15 patients, with complete recovery at discharge. The autologous blood transfusion volume (P = 0.009, r = 0.36) and the total aortic clamping time (P = 0.04, r = 0.30) were correlated with renal dysfunction. CONCLUSION: Postoperative renal dysfunction based on the variation in creatinine serum level was transient and requires further investigation using sensitive biomarkers for tubular ischemia.

Radiofrequency ablation under extracorporeal membrane oxygenation for atrial tachycardia in postpartum.

Tachycardia-mediated cardiomyopathy associated with cardiogenic shock is a rare but well-known entity. We report an unusual case of cardiogenic shock with atrial tachycardia in postpartum; the patient underwent successful radiofrequency ablation under extracorporeal membrane oxygenation (ECMO). Radiofrequency ablation is usually used to treat this clinical situation. The use of ECMO has been described only in pediatric case.

The Perception of the Anesthesiologist Among the Medical, Paramedical and Administrative Staff.

Introduction: Anesthesia remains a young medical discipline still relatively unknown by the general public and probably by some health professionals. The objective of the study was to evaluate the perception of anesthesiologist by health professionals working with this specialty. Methods: We distributed a computerized survey to physicians, residents, paramedical, midwives, and administrative staff in different hospitals between April and July 2018 in Normandy, France. The survey included 38 questions on 6 different topics: communicated image, skills and knowledge, communication, place in patient care, workload, and initial anesthesiologist formation. The survey was validated by a semi-directive interview methodology. A Likert scale from ×2 to +2 ("completely disagree" to "completely agree") was used for each item. Results: Six hundred and twenty five out of 2,000 surveys sent were analyzed. The anesthesiologist conveys an image of serenity (+0.94 ± 0.79), has a high degree of responsibility (+1.72 ± 0.59) with important decision-making power (+1.39 ± 0.82). He guarantees patient safety and comfort (+1.07 ± 0.88) with his/her dual competence in anesthesia and intensive care (+1.36 ± 0.82). Anesthesiology requires teamwork (+1.68 ± 0.58) and good communication skills (+1.48 ± 0.73). The anesthesiologist is not perceived as a service provider (-0.33 ± 1.15) but is the physician responsible for perioperative care (+1.69 ± 1.00). His/her workload is moderately perceived as high (+0.71 ± 1.17) but is confronted with potentially conflictual relationships with colleagues from other specialties (+1.40 ± 0.68) and stressful situations (+1.44 ± 0.80). Conclusion: The overall perception of the anesthesiologist in our study appears to be good.

Effect of early hyperoxemia on mortality in mechanically ventilated septic shock patients according to Sepsis-3 criteria: analysis of the MIMIC-III database.

BACKGROUND AND IMPORTANCE: Hyperoxemia may be associated with increased mortality in emergency room or ICU patients. However, its effect during septic shock is still debated. OBJECTIVE: To evaluate the effect of hyperoxemia on ICU mortality, during the first 24 h of ICU stay, in mechanically ventilated patients with septic shock according to SEPSIS-3 criteria. DESIGN, SETTINGS AND PARTICIPANTS: A retrospective cohort study of ICU admissions recorded in the Medical Information Mart for Intensive Care-III, a retrospective ICU database, was performed. INTERVENTION: Two oxygen exposures during the first 24 h were compared: average PaO2 (TWA-PaO2) between 70 and 120 mmHg in the normoxemia group and above 120 mmHg in the hyperoxemia group. OUTCOME MEASURES AND ANALYSIS: The primary outcome was mortality during ICU stay. MAIN RESULTS: Four hundred eighty-eight ICU admissions met the inclusion criteria: 214 in the normoxemia group and 274 in the hyperoxemia group. The median TWA-PaO2 was 99.1 (88.9-107.6) mmHg in the normoxemia group and 151.5 (133.6-180.2) mmHg in the hyperoxemia group. ICU mortality was lower in the hyperoxemia group than in the normoxemia group in univariate analysis [29.6 vs. 39.7%, respectively; OR 0.64 (0.44-0.93); P = 0.024], but not in multivariate analysis [OR 0.98 (0.62-1.56); P = 0.93]. There was no difference between the two groups in ICU length of stay [8.0 (4.3-15.0) vs. 8.4 (4.7-15.0) days; P = 0.82]. CONCLUSION: We did not find any impact of early hyperoxemia on mortality in this population of mechanically ventilated patients with SEPSIS-3 septic shock criteria.

Safety of day surgery for patients with special needs.

BACKGROUND: The objective of this study was to assess the safety and quality of day care management for dental surgery under general anaesthesia in a population with special needs and to compare the results with a control population. METHODS: A retrospective observational cohort study was performed. The study population included all patients who had day care dental surgery under general anaesthesia for one year. The primary endpoint was the rate of unscheduled admission, which was defined as the unplanned need to maintain a hospital stay on the evening of the surgical procedure. Secondary endpoints included occurrence of complications during the perioperative period (either anaesthesia or surgery related) on the day of surgery (D0) and on day 1 and satisfaction of patients or their relatives. RESULTS: Data from 138 patients (70 with special needs and 68 controls) were analysed. In both groups, patients were young (mean age 33 years ± 14 in each group). Special needs were mainly related to autism (34%), cerebral palsy (19%), intellectual disability (19%) and Down syndrome (10 %). Surgical procedures were more extensive in the control group. There was 1 unscheduled admission in the special needs group and 3 in the control group (RR 0.32, 95% CI [0.03; 3.04]). There was no difference in the rate of complications. CONCLUSION: In our cohort, day care management for dental surgery under general anaesthesia is safe and effective for patients with special needs.

Evaluation of the Time Spent by Anesthetist on Clinical Tasks in the Operating Room.

BACKGROUND: Changes in the health system in Western countries have increased the scope of the daily tasks assigned to physicians', anesthetists included. As already shown in other specialties, increased non-clinical burden reduces the clinical time spent with patients. METHODS: This was a multicenter, prospective, observational study conducted in 6 public and private hospitals in France. The primary endpoint was the evaluation by an external observer of the time spent per day (in minutes) by anesthetists on clinical tasks in the operating room. Secondary endpoints were the time spent per day (in minutes) on non-clinical organizational tasks and the number of task interruptions per hour of work. RESULTS: Between October 2017 and April 2018, 54 anesthetists from six hospitals (1 public university hospital, two public general hospitals and three private hospitals) were included. They were followed for 96 days corresponding to 550 hours of work. The proportion of overall clinical time was 62% (58% 95%CI [53; 63] for direct care. The proportion of organizational time was higher in public hospitals (11% in the university hospital (p < 0.001) and 4% in general hospitals (p < 0.01)) compared to private hospitals (1%). The number of task interruptions (1.5/h ± 1.4 in all hospitals) was 4 times higher in the university hospital (2.2/h ± 1.6) compared to private hospitals (0.5/h ± 0.3) (p < 0.05). CONCLUSIONS: Most time in the operating room was spent on clinical care with a significant contrast between public and private hospitals for organizational time.

Contribution of the anatomy laboratory to the practical training of residents in regional anesthesia.

INTRODUCTION: Dissection workshop has never been assessed in the initial training of resident medical students in anesthesia. This work aimed at assessing the impact of this educational tool on the rates of success of the main blocks the resident in anesthesia achieved during their training. MATERIALS AND METHODS: The primary outcome measure studied in this work was the self-assessment by the resident of the rate of success of every block before and after the complementary training in regional anesthesia included dissection workshop, determined by a questionnaire sent by post at least 6 months after the teaching. Besides, the seminar was estimated at once by a questionnaire evaluating the quality as well as the interest of the education on a scale ranging from 0 to 10. RESULTS: Forty-two anesthesia residents went through the training. Thirty-four (77%) handed back the questionnaire assessing the global interest an average of 8.9 (1.4). Theoretical training received an average score of 7.7 (1.4) and dissection workshop in anatomy laboratory, a score of 7.8 (1.6). The quality of teaching methods used was marked nine (0.8). Twenty-seven residents (61.36%) mailed the questionnaire. The rate of success concerning each block in their clinical practice before and after the training is not different, only concerning the humeral canal block. CONCLUSION: Although the educational quality of the training was acknowledged as responding to the expectancies of the anesthesia residents, the dissection workshop do not meet with the expected requirements of rates improval of the different blocks part from the humeral canal one's, within this medical sample in initial training.

Efficiency of Text Message Contact on Medical Safety in Outpatient Surgery: Retrospective Study.

BACKGROUND: Establishing pre- and postoperative contact with patients is part of successful medical management in outpatient surgery. In France, this is mostly done via telephone. Automated information with short message service (SMS) reminders might be an interesting alternative to increase the rate of compliance with preoperative instructions, but no study has shown the safety of this approach. OBJECTIVE: The objective of this study was to evaluate the impact of pre- and postoperative automated information with SMS reminders on medical safety in outpatient surgery. METHODS: We conducted a retrospective, single-center, nonrandomized, controlled study with a before-after design. All adult patients who had outpatient surgery between September 2016 and December 2017 in our university hospital center were included. Before April 2017, patients were contacted by telephone by an outpatient surgery nurse. After April 2017, patients were contacted by SMS reminder. All patients were contacted the day before and the day after surgery. Patients contacted by SMS reminder were also contacted on day 7 after surgery. The primary end point was the conversion rate to full-time hospitalization. Secondary end points were hospitalization causes (anesthetic, surgical, organizational) and hospitalization costs. RESULTS: A total of 4388 patients were included, 2160 before and 2228 after the introduction of SMS reminders. The conversion rate to full-time hospitalization was 34/4388 (0.77%) with a difference between SMS group (8/2228, 0.36%) and telephone group (26/2160, 1.20%). The cost of SMS reminders was estimated as half that of telephone calls. CONCLUSIONS: In this work, we report a decrease in the rate of conversion to full-time hospitalization with the use of pre- and postoperative SMS reminders. This new approach could represent a safe and cost-effective method in an outpatient surgery setting.