Preoperative frailty assessment: a review.

Elderly surgical population is growing faster than the rate of population ageing. The risk of postoperative complication is higher in this population, the type of complication and the risk indicators are different from younger patients. There is also a huge heterogeneity in the elderly population. The concept of frailty-emerges to explain these specific aspects and to risk stratify older patients. The present work intends to help the anaesthesiologist to take into account the concept of frailty at the preoperative visit. We reviewed, in the light of surgical context, the physiopathology of ageing, the definitions of frailty concept,the current existing strategies for peri-operational optimisation and the different frailty assessment tools. Our conclusions are that preoperative frailty assessment is essential in modern perioperative medicine practice and that the Edmonton Frail Scale stands out from other tools even though it cannot yet be considered as a gold standard.

The anti-inflammatory effects of ketamine: state of the art.

Inflammation is a major component in keeping the body in homeostasis. However, an overwhelmed inflammatory response may be associated to a loss of this homeostatic status, which may lead to tissue injury or organ dysfunction. A huge number of drugs interacts with the inflammatory response in a positive, negative or "dual" manner. Among these drugs, ketamine seems to have a significant positive effect on the regulation of inflammation. This NMDA-receptor antagonist acts at different levels of inflammation, interacting with inflammatory cells recrutment, cytokins production, and inflammatory mediators regulation. The resultant effect of these interactions confers to ketamine a anti-proinflammatory effect by limiting exacerbation of systemic inflammation without affecting local healing processes. This review makes a complete overview of the immunomodulatory properties of this complex anesthetic substance.

Spinal Cord Infarction in the Course of a Septic Shock: About One Case and Review of the Literature.

We report the case of a patient admitted to our intensive care unit in the course of a septic shock, secondary to cholangitis. After rapid hemodynamic stabilization, antibiotherapy, and endoscopic extraction of bile ducts stones, she appeared to have developed flaccid paraplegia. The suspected diagnosis of medullar ischemia was confirmed by typical MRI findings. This case stresses the potential pathogenic role of hypotension in medullar ischemia and the place of magnetic resonance imaging (MRI) as a reliable diagnostic tool.

Major thoracic surgery during long-term extracorporeal lung assist for treatment of severe adult respiratory distress syndrome (ARDS).

Surgery in patients treated with extracorporeal lung assist (ELA) carries a high risk of life threatening bleeding complications caused by the need for systemic anticoagulation. A case report describing a successful surgical intervention for the repair of a broncho-pleural leakage by thoracotomy during ELA is presented. A newly developed heparin coated extracorporeal system was used in a patient being treated for severe adult respiratory distress syndrome (ARDS) after left sided pneumectomy. The heparin coated system allowed discontinuation of systemic heparinization intraoperatively without coagulation complications related to the extracorporeal system. This procedure was followed by resolution of the ARDS.

Extracorporeal lung assist with heparin-coated systems.

Extracorporeal lung assist (ELA) has been recommended for the treatment of ARDS if conventional therapy fails. However, the need for nearly complete anticoagulation is a major risk factor for hemorrhagic complications. We describe our experience with 13 ARDS patients treated with ELA using heparin-coated systems (Carmeda). Maintaining partial thromboplastin time and activated clotting time within or close to the normal range, even major surgery (20 thoracotomies and 2 laparotomies) could be performed without undue bleeding complications related to anticoagulation during extracorporeal support. Eight of the 13 patients survived. The use of heparin-coated systems allows prolonged ELA with nearly physiological coagulation function, permitting major surgical intervention. It enhances the safety margin of extracorporeal gas exchange and may ultimately extend its indications.

[Traumatic myocardial infarction caused by lead shot]. / Infarctus du myocarde traumatique par plomb de chasse.

The authors report the case of a 32 year old woman who was shot with a shotgun. Acute inferior wall infarction was detected fortuitously on electrocardiography and coronary angiography showed occlusion of the right coronary artery with lead shot. The single coronary lesion, absence, of other cardiac complications (haemopericardium, cardiac perforation, ...) and the favourable outcome with conservative medical treatment has not been previously reported to the authors' knowledge.

[Blood economy during surgery (author's transl)]. / Economie de sang en chirurgie.

Three methods exist for economizing blood during surgical operations: deferred autotransfusion and intentional hemodilution provide blood of excellent quality without any marked risk to the patient. Autotransfusion during operation is a less burdensome method which recuperates blood lost during surgery. The quality of the blood depends upon the type of operation (excellent in elective vascular surgery). Techniques and qualitative and quantitative results are described for each method.