Tissue near infra red spectroscopy change is not correlated with patients' outcome in elective cardiac surgery.

BACKGROUND: Microcirculatory disturbances following cardiac surgery with cardiopulmonary bypass (CPB) are thought to be at the origin of organ dysfunction, although few studies have correlated microvascular alterations with outcome. We aimed to assess the microcirculation with near infrared spectroscopy (NIRS) and correlate NIRS parameters with intensive care length of stay and organ dysfunction. METHODS: Forty patients at increased risk of postoperative systemic inflammatory response syndrome after an elective cardiac surgery with CPB were included in this prospective observational study. Microcirculation of the thenar eminence was analysed by NIRS technology, through the tissue oxygen saturation (StO2 ) and the recovery slope after an ischaemic challenge. Organ dysfunction was assessed with the Sequential Organ Failure Assessment (SOFA) score. Microcirculation parameters were recorded at baseline, at different time points during the surgery and the first 48 postoperative hours. RESULTS: StO2 at baseline was 82% and decreased significantly until 77% at 2 h after CPB. Recovery slope values were 4.3% per second at baseline and decreased to 2.5% per second during CPB (P < 0.05). From 12 h after CPB time point, both parameters were not statistically different from baseline anymore. We found no correlation between microcirculatory parameters and mean arterial pressure, cardiac index, intensive care unit (ICU) length of stay or SOFA score. CONCLUSION: This study confirms, through a non-invasive technology, a significant but transient alteration of the microcirculation during elective cardiac surgery. However, as these microvascular alterations were not correlated with patient's outcome, NIRS-derived parameters seem to be of limited interest in the cardiac surgery setting.

Haemodynamic consequences of etomidate administration in elective cardiac surgery: a randomized double-blinded study.

BACKGROUND: The consequences of inhibition of cortisol synthesis by a single dose of etomidate on subsequent vasopressor drug usage and the duration of relative adrenal insufficiency (RAI) after cardiac surgery are not known. METHODS: This was a prospective, randomized, double-blinded controlled trial of 100 patients undergoing elective cardiac surgery and receiving either etomidate or propofol at induction of anaesthesia. A short corticotropin test was performed 12, 24, and 48 h after anaesthesia induction. RAI was defined as a response <250 nmol litre(-1). RESULTS: The mean (sd) norepinephrine infusion rate during the first 48 postoperative hours was 0.11 (0.01) and 0.11 (0.01) µg kg(-1) min(-1) in the etomidate and propofol groups, respectively (P=0.89). Time to norepinephrine withdrawal was similar between the groups. The incidence of RAI was higher in the etomidate group at 12 h (100% vs 41%, P<0.001) and 24 h (85% vs 25%, P<0.001). CONCLUSIONS: A single bolus of etomidate blunts the hypothalamic-pituitary-adrenal axis response for more than 24 h in patients undergoing elective cardiac surgery, but this was not associated with an increase in vasopressor requirements.

Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017.

Infection is a risk for any intervention. In surgery, for example, pathogenic bacteria are found in more than 90% of operative wounds during closure. This exists whatever the surgical technique and whatever the environment (the laminar flow does not entirely eliminate this risk). These bacteria are few in number but can proliferate. They find in the operative wound a favourable environment (haematoma, ischaemia, modification of oxido-reduction potential...) and the intervention induces anomalies of the immune defences. In the case of the installation of foreign material, the risk is increased. The objective of antibiotic prophylaxis (ABP) is to prevent bacterial growth in order to reduce the risk of infection at the site of the intervention. The preoperative consultation represents a privileged moment to decide on the prescription of a ABP. It is possible to define the type of intervention planned, the associated risk of infection (and therefore the necessity or not of ABP), the time of prescription before surgery and any allergic antecedents which may modify the choice of the selected antibiotic molecule.

Hospital-acquired infections documented by repeated annual prevalence surveys over 15 years.

OBJECTIVE: To estimate the benefits of iterative prevalence surveys in detecting trends of hospital-acquired infections (HAIs). METHODS: On the basis of the French protocol for national prevalence studies, HAI data of 15 consecutive annual surveys performed at the same period by the same group of investigators was gathered in a single database to describe the trend of HAIs in a University Hospital over a 15-year period. RESULTS: A total of 20,401 patients were included. Overall, the prevalence of patients presenting with at least one HAI acquired in our University Hospital was 5.1% [95% CI, 4.8-5.4%]. The prevalence of HAIs and antimicrobial drug use significantly decreased over time (P<0.01). CONCLUSION: Despite limitations, repeated prevalence surveys can be a useful tool for promoting control measures to better prevent HAIs.

Effect of mandibular nerve block on postoperative analgesia in patients undergoing oropharyngeal carcinoma surgery under general anaesthesia.

BACKGROUND: Postoperative analgesia after oropharyngeal carcinoma surgery remains poorly studied. This study investigates the effects of mandibular nerve block (MNB) with ropivacaine 10 mg ml(-1) in conjunction with general anaesthesia (GA) on postoperative analgesia after partial glossectomy or transmandibular lateral pharyngectomy. METHODS: In a randomized double-blind study, 42 patients (21 in each group) received an MNB by the lateral extra-oral approach (MNB group) or a deep s.c. injection of normal saline (control group). Both groups received a standardized general anaesthetic. Postoperative analgesia included fixed dose of i.v. acetaminophen and morphine via a patient-controlled analgesia device. Consumption of morphine and supplemental analgesics and pain scores at rest were measured. RESULTS: The mean cumulative morphine consumption was reduced by 56 and 45% at 12 and 24 h after operation in the MNB group. The administration of analgesic rescue medications was delayed in the MNB group. The visual analogue scale (VAS) pain scores were comparable in the two groups during the first 24 h. Adequate analgesia (mean VAS < or = 3) was observed throughout the study period in the MNB group, but only from 4 h after operation onwards in the control group. The number of patients who experienced severe pain (VAS > 7) during the first postoperative day was lower in the MNB group than in the control group (3 vs 10. respectively, P < 0.05). CONCLUSIONS: In this study, MNB performed before GA for oropharyngeal carcinoma surgery improved postoperative analgesia, resulting in reduced morphine consumption at 24 h and severe pain in fewer patients.

[Outcomes and quality of life of elderly patients older than 80 years three months after a stay in an intensive care unit]. / Devenir et qualité de vie d'une population âgée de plus de 80 ans trois mois après un séjour en réanimation.

OBJECTIVES: The aging of the population has seen an increase in the number of elderly patients admitted to reanimation units. We sought to know the outcomes and evolution of the quality of life of a population of elderly patients after their experience with this type of service. METHOD: We included all patients older than 80 years who had been in two intensive care units in the Loire region of France between October 2005 and May 2006. We studied their state of mind 3 months after they exited the service. Then, for the survivors, we used the Activities of Daily Living (ADL) scale and the generic questionnaire of health, the SF-36, to evaluate the evolution of their degree of autonomy and quality of life related to health compared to that one month prior to entry in the reanimation unit. RESULTS: We included 70 patients (mean age 85.2+/-4.5 years). At 3 months after exiting reanimation, the survival rate was 57%, and 28 survivors underwent rating scale testing. The physical score of the SF-36 and the ADL score were significantly decreased as compared with that one-month before admission, with no significant difference in mental score of the SF-36. Physical deterioration did not have a significant effect on the evolution of perceived health (dimension GH of the SF-36), life and relations with others (dimension SF) or mental health (dimension MH). The decreased ADL score was correlated with that of the two physical dimensions of the SF-36, with no correlation with the four psychic dimensions. A total of 92% of patients were satisfied with their care in reanimation and three of four would agree to go back if their state required it. For the others, it is a question of respecting the will of the elderly patients confronted with reanimation care. CONCLUSION: Three months after intensive care with reanimation, elderly patients do not have significantly modified perceived health and psychic state as compared with objective deteriorated physical capacity. The absence of consensus on the threshold of old age and the quality-of-life instrument to use prevents a comparison of our results with those in the literature. However, others have shown and we agree that elderly people could benefit from reanimation therapy.

Extensively drug-resistant bacteria: Which ethical issues?

OBJECTIVE: The increased bacterial resistance to antibiotics has now become a public health concern. How can we preserve the well-being of patients presenting with infections caused by extensively drug-resistant bacteria (EDRBs) and that of their contacts without inducing any loss of chance of survival, all the while living together and controlling the spread of these EDRBs? METHOD: Terre d'éthique, a French territorial ethics committee, was asked to reflect on this topic by the infection control unit of a French University Hospital as it raises many ethical issues. RESULTS: Patients are at the core of any ethical approach, and respecting their autonomy is fundamental. Patients should be adequately informed to be able to give consent. Indeed, the creation and dissemination of a register (list of names of contacts or infected patients) entails responsibility of the infected person and that of the community. This responsibility leads to an ethical dilemma as protecting the group (the whole population) necessarily means limiting individual freedom. The principle of autonomy should thus be compared with that of solidarity. Is medical confidentiality an obstacle to the sharing of information or lists of names? CONCLUSION: We did not aim to answer our problematic but merely wanted to show the complexity of EDRB spread in a broader societal and economic context, all the while respecting the rights of patients.

[HELLP syndrome and ruptured subcapsular hepatic haematoma. Case report and therapeutic options]. / HELLP syndrome et hématome sous-capsulaire du foie rompu. Stratégie thérapeutique à partir d'un cas clinique.

We report a case of spontaneous hepatic rupture secondary to HELLP syndrome. A favourable evolution was observed after massive transfusion and surgical management limited to hepatic packing. Subcapsular hepatic haematoma is a rare complication of preeclampsia occurring mainly in the context of HELLP syndrome. A high maternal and foetal mortality is observed. Different therapeutic options are presented including medical, surgical and radiological interventions. A unique strategy cannot be defined. Multidisciplinary approach seems mandatory. Surgery should remain as less aggressive as possible.

Glucose-lipid ratio is a determinant of nitrogen balance during total parenteral nutrition in critically ill patients: a prospective, randomized, multicenter blind trial with an intention-to-treat analysis.

OBJECTIVE: Protein sparing, the major goal of nutritional support, may be affected by the glucose/lipid ratio. This study in critically ill patients compared the efficacy and tolerance of two isocaloric isonitrogenous total parenteral nutritions (TPN) having different glucose/lipid ratios. DESIGN: Multicentric prospective randomized study. PATIENTS: 47 patients with SAPS I score higher than 8 and requiring exclusive TPN. INTERVENTIONS: Patients received glucose/lipid ratios of 50/50 or 80/20. For 7 days all patients received 32 glucidolipidic kcal/kg and 0.27 g/kg nitrogen daily. All-in-one bags were prepared using industrial mixtures and a fat emulsion. MEASUREMENTS AND RESULTS: We determined TPN efficacy by nitrogen balance, urinary 3-methylhistidine/creatinine ratio, transthyretin and tolerance by glycemia, and liver enzymes. After controlling for five variables with significant effects, patients receiving the 50/50 ratio during TPN had significantly higher nitrogen balance than those receiving the 80/20 ratio. The daily difference in mean nitrogen sparing effect in favor of the latter group was 1.367 g (95% CI 0.0686-2.048). Glycemia on day 4 and gamma-glutamyltranspeptidase on day 8 were higher in group receiving the the 80/20 ratio. CONCLUSIONS: In critically ill patients TPN at a glucose/lipid ratio of 80/20 ratio induces a small nitrogen sparing effect compared to the ratio of 50/50, at the expense of poorer glycemic control. The clinical significance is unclear.

[Evolutionary comparison of laboratory cardiac and infectious parameters during septic shock: about an original case]. / Evolution comparée des indicateurs biologiques cardiaques et infectieux lors du choc septique: à propos d'une observation originale.

A massive release of troponin Ic and CKMB was described in a patient during septic shock. According to experimental animal models previously described, this release of biological markers by myocardial tissue could be due to an inflammatory process of myocardial tissue during septic shock without myocardial infarction in non cardiac critically ill patients.

Short- and long-term prognosis, functional outcome following ICU for elderly.

Among 1532 ICU patients we analysed 295 elderly patients (19%) aged more than 70-years-old. We determined prospectively the immediate and subsequent one-year outcome with a study of the predictive value of their ICU admission parameters. Then we followed the ICU survivors over the year after discharge (1, 6, 12 months) by quality of life questionnaires. ICU mortality was 26.7%; SAPS was the only predictor of short term mortality. On ICU discharge, 216 elderly were followed at 1, 6, 12 months; the one-year cumulative mortality was 49% from ICU discharge, majority of deaths occurring over the first month. Age, previous health status and SAPS had a predictor value of one-year mortality for ICU survivors. 103 patients were alive at one year: 88% returned to home, 72% had a relatively good functional status allowing an independent life, and 82% had the same or improved functional status.

Contribution of ultrasonography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients.

OBJECTIVES: To assess the respective value of ultrasonography (US) and morphine cholescintigraphy (MC) in the diagnosis of acute acalculous cholecystitis (AAC). DESIGN AND SETTING: Prospective study in an intensive care unit of a university hospital. PATIENTS AND INTERVENTION: Twenty-eight patients with clinically and biologically suspected of AAC. US was performed at the bedside and less than 12 h later MC. US was considered positive if three major criteria were present: wall thickness greater than 4 mm, hydrops, sludge; MC results were regarded as positive if the gallbladder could not be visualized. These latter patients underwent cholecystectomy and the diagnosis of AAC was confirmed through histopathological study. MEASUREMENTS AND MAIN RESULTS: Sensitivity of US and MC, respectively, was 50% and 67%, specificity 94% and 100%, positive predictive value 86% and 100%, negative predictive value 71% and 80%, and accuracy 75% and 86%. The correlation between US and MC findings was 71%, with chi = 0.31. By Bayesian analysis the probability of disease if the MC finding was positive was 100% regardless of US results. A positive US finding was associated with a 86% probability of disease, but with a probability of only 66% in case of negative MC results. MC is thus superior to US for confirming AAC in selected critically ill patients. Nevertheless, US is an easy, noninvasive, and effective method of bedside screening. The combination of the two imaging tests improves diagnostic accuracy and reduces false-positive and false-negative rates. Poor agreement between the two tests leads to better diagnostic complementarity.

Prevention of nosocomial pneumonia in intubated patients: respective role of mechanical subglottic secretions drainage and stress ulcer prophylaxis.

Chronic microaspiration through a tracheal cuff is the main culprit in the penetration and colonization of the lower respiratory tract. A total of 145 patients intubated for more than 3 days were randomly assigned to a double nosocomial pneumonia (NP) prevention: 1--Prevention of aspiration by hourly subglottic secretion drainage (SSD) with a specific endotracheal tube (HI-LO Evac tube, Mallinckrodt); 2--Prevention of gastric colonization using either sucralfate or antacids. Four random groups were defined, similar in age and severity of illness. Subglottic secretion drainage treatment was associated with: a) a twice lower incidence of NP (no-SSD: 29.1%, SSD: 13%); b) a prolonged time of onset of NP (no-SSD: 8.3 +/- 5 days, SSD: 16.2 +/- 11 days); c) a decrease in the colonization rate from admission to end-point day in tracheal aspirates (no-SSD: +21.3%, SSD: +6.6%) and in subglottic secretions (no-SSD: +33.4%, SSD: +2.1%). Sucralfate was not associated with a significantly lower incidence of NP (antacids: 23.6%, sucralfate: 17.8%), but with a lower increase in the colonization rate in subglottic and gastric aspirates, from admission to end-point day.

Prospective study of nosocomial colonization and infection due to Pseudomonas aeruginosa in mechanically ventilated patients.

OBJECTIVE: To investigate the respective contribution of endogenous and exogenous transmission of Pseudomonas aeruginosa in the colonization of lungs in the mechanically ventilated patient, to estimate the role of P. aeruginosa colonization in the occurrence of severe infections, and to extrapolate appropriate control measures for the prevention of P. aeruginosa ventilator-associated pneumonia. DESIGN: Prospective study of the presence of P. aeruginosa (in stomach fluid, throat specimens, stool, and sputum) on admission, twice a week throughout the patient's stay, and in their environment. O-serotyping, pulsed-field gel electrophoresis, and arbitrarily-primed polymerase chain reaction were used to characterize the strains. SETTING: The two intensive care units (ICUs 1 and 2) of a university hospital. PATIENTS: During a 6-month period, 59 patients were included (21 in ICU 1 and 38 in ICU 2). RESULTS: P. aeruginosa was isolated in 26 patients, including ten pneumonia cases and seven colonizations on admission. The incidence of acquired colonization was statistically different between the two ICUs: 5.5 and 20.5 per 1000 days of mechanical ventilation, in ICUs 1 and 2, respectively. Endogenous acquisition was the main origin of P. aeruginosa colonization (21 of 26 patients) and the upper respiratory tract was the main bacterial reservoir in broncho-pulmonary colonization and infection. However, during the 6-month period of the study, a multidrug-resistant strain of P. aeruginosa O:11, isolated in the sink of the room of 12 patients, was found responsible for two colonizations (1 digestive, 1 throat/lungs) and one pneumonia. As a whole, from 26 cases of colonization/infection with P. aeruginosa, 5 were related to an exogenous contamination (environmental reservoir in 4 patients and cross-contamination in one patient). CONCLUSIONS: These results emphasize the need for applying various infection control measures to prevent colonization of patients with P. aeruginosa, including strategies to limit the potential of sinks from acting as a source or reservoir for this bacterium.

Ventilator temperature sensors: an unusual source of Pseudomonas cepacia in nosocomial infection.

A prospective study was undertaken to determine the source of Pseudomonas cepacia colonization and infection that had affected ventilated patients in an Intensive Care Unit (ICU) for three years. Thirty-eight patients undergoing mechanical ventilation were enrolled during a six-week period. Samples were taken from patients, ventilator circuits and the environment for culture. P. cepacia was isolated from the condensate formed in the ventilator circuit and the source of the contamination was shown to be the temperature sensor. Ribotyping of the representative strains of P. cepacia performed with two endonucleases, EcoRI and PvuII, confirmed the homogeneity of the isolates from patients and ventilator circuits. A modification of the procedure for disinfection of the temperature sensors resulted in the eradication of P. cepacia from the ICU.

[Risk of infection and locoregional anesthesia]. / Risque infectieux et anesthésie locorégionale.

We analysed the data on the risk of infection during practice of locoregional anaesthesia (LRA) and propose recommendations for its prevention. The epidemiologic data show that the incidence is very low. The risk of LBA during sepsis is uncertain and the data are often contradictory. The benefit-risk ratio must be considered, specifically in obstetrics. Precautions which must be followed during the practice of LRA are discussed.

[Localized rhabdomyolysis after anaphylactic shock caused by suxamethonium]. / Rhabdomyolyse localisée apés un choc anaphylactique au suxaméthonium.

A young woman without remarkable medical history, experienced a life threatening anaphylactoid reaction after induction of general anaesthesia for an emergency curettage. Hypersensitivity reaction involving IgE antibodies against suxamethonium was proven by positive skin test and detection of specific IgE by radio-immuno assay. After intensive therapy for 2 to 3 hours, the patient exhibited rhabdomyolysis localized on both calves. This complication, which required fasciotomies, did not result in renal failure. Local and general outcome was good. Rhabdomyolysis was due to compartmental ischaemia following shock and local external compression in the lithotomy position.

[Cerebral pneumocephalus after epidural anesthesia: a rare complication?]. / La pneumatocèle cérébrale après anesthésie péridurale: une complication rare?

A case is reported of pneumoencephalus occurring after an accidental dural puncture during a cervical epidural puncture using the loss of resistance technique. Six ml of air were injected intrathecally. The patient recovered spontaneously within five days. This complication may occur more frequently than commonly admitted. It may be difficult to differentiate between headache due to pneumoencephalus and that by stretching of the meninges due to cerebrospinal fluid leakage. Only a CT scan can help to answer this question.

[Cervical epidural anesthesia]. / Anesthésie péridurale cervicale.

Cervical epidural anaesthesia (CEA) results in an effective sensory blockade of the superficial cervical (C1/C4) and brachial plexus (C5/T1-T2). It is used both intraoperatively and in the treatment of postoperative or chronic pain. The approach to the epidural space at the C7-T1 interspace is not technically difficult. Patients are placed in the sitting position, increasing the negative pressure in the epidural space, with the head flexed on the thorax, in order to open the lowest cervical interspace. A 18-gauge Tuohy needle is inserted by a midline approach into the C6-C7 or C7-T1 interspace. A catheter may be inserted and left in place for postoperative analgesia. Local anaesthetics are administered either alone, or in combination with opiates. The CEA blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required. Cervical epidural anaesthesia may be used either alone, or in combination with general anaesthesia depending on the surgical procedure. This technique seems to be effective in carotid artery surgery since sensitive and reliable information on cerebral function may be obtained. It is also for shoulder and upper limb surgery as well as for pharyngolaryngeal surgery, providing efficient operative anaesthesia and postoperative analgesia. CEA is used for relief of chronic pain in the head and neck or cancer pain due to Pancoast-Tobias syndrome. It seems to be effective for treating pain in patients with unstable angina pectoris or acute myocardial infarction.

[Neurotoxic role of glycocolle and derivatives in transurethral resection of the prostate]. / Rôle neurotoxique du glycocolle et de ses dérivés au cours de la résection transuréthrale de la prostate.

72-year-old patient underwent an elective transurethral resection of the prostate (TURP) performed with a spinal anaesthesia. The irrigation solution contained glycine at a concentration of 15 g.l-1. The patient's level of consciousness deteriorated over the next 4 hours. He went in an areflexic coma with pupillary areflexia and left mydriasis. The diagnosis of TUR syndrome was substantiated by a sodium blood concentration of 98 mmol.l-1, an osmotic gap of 48 mosmol.kg-1 and blood ammonia at 415 mumol.l-1. To investigate the pathophysiological role of glycine and its metabolites, their concentrations were measured by chromatography and spectrometry in plasma and CSF 8, 24 and 48 hours postoperatively. Glycine and its metabolites (serine, alanine, glyoxylic acid and glycolic acid) accumulated during the postoperative period in both blood and CSF. The central nervous system is in direct contact with these neurotropic compounds. Glycine is an inhibitory neurotransmitter, whereas glyoxylic acid and glycolic acid are considered as to be neurotoxic.