Example of cost calculations for an operating room and a post-anaesthesia care unit.

OBJECTIVE: The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. METHODS: Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). RESULTS: The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. CONCLUSION: Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making.

[Prolonged phase II neuromuscular blockade following succinylcholine administration]. / Bloc dépolarisant de phase II et curarisation prolongée après un bolus de succinylcholine.

Patients who are given a single dose of succinylcholine normally undergo a short-acting depolarizing phase I neuromuscular block but rarely a phase II block. Prolonged neuromuscular blockade occurs after a single dose of succinylcholine in case of genetically determined abnormal plasma butyrylcholinesterase activity. It is mandatory to use monitoring to detect this side effect. We report a case of a patient with abnormal plasma butyrylcholinesterase activity undergoing a six-hour prolonged neuromuscular phase II block, after a single dose of succinylcholine.

[Prolonged residual paralysis after a single intubating dose of rocuronium: an unexpected cause]. / Bloc résiduel prolongé après injection unique de rocuronium pour l'intubation : une étiologie originale.

Postoperative curarization following a single dose of rocuronium is a known risk quickly diagnosed through the monitoring of neuromuscular blockade. Different etiologies can cause a prolonged block. We report the case of a misdiagnosis of prolonged neuromuscular blockade by a failure in the monitoring system of curarization.

[Fast recovery of haemodynamic and ventilatory functions after sugammadex bolus following rocuronium-induced anaphylactic shock refractory to conventional treatment]. / Récupération hémodynamique et ventilatoire rapide après injection de sugammadex lors d'un choc anaphylactique au rocuronium, réfractaire au traitement conventionnel.

Recently, three case reports have suggested the possible efficacy of sugammadex in anaphylactic shock refractory to conventional treatment induced by rocuronium. We report a new case of severe anaphylactic reaction to rocuronium treated with sugammadex. After 18 minutes of conventional treatment because of persistent cardiocirculatory failure and bronchospasm, a bolus of 2000 mg (18 mg/kg) of sugammadex was injected. This was associated with rapid correction of arterial hypotension and bronchoconstriction. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are unknown but it is important to know that refractory anaphylactic shock to rocuronium can be potentially corrected with sugammadex.

[Clinical evaluation of post-surgical bleeding after a sugammadex injection]. / Évaluation clinique du saignement post-chirurgical après injection de sugammadex.

OBJECTIVE: Sugammadex reverses neuromuscular blockade by chemical encapsulation of nondepolarizing neuromuscular blocking drugs (rocuronium and vecuronium). The imprint of this new molecule has recently been supplemented with a section on haemostasis notifying a longer clotting time without documented clinical consequences. This has resulted in recommendations on the use of sugammadex in the presence of coagulation disorders (pharmacologically-induced or not). The objective of this study was to analyze the experience gathered with this molecule on clinically-evaluated bleeding. No study on this subject is currently available. METHODS: This is a retrospective study over 1 year between August 2009 and August 2010. All patients with laparotomies for cancer surgery requiring suction drains were included. Patients were allocated to groups according to the type of reversal (without sugammadex versus sugammadex 2 or 4 mg/kg). The endpoint was clinically-evaluated postoperative bleeding (reoperation for haemostasis, blood-stained laparotomy dressings in the post-anaesthesia care unit [PACU], cumulative volume collected in suction drains upon arrival in PACU and then after 2 hours and the next morning at 6a.m). RESULTS: One hundred and ninety-three patients were included in three groups, 78 in the group "without sugammadex", 95 in "sugammadex 2mg/kg" and 20 in "sugammadex 4 mg/kg". There were no reoperations for haemostasis. The comparison among different groups for the endpoint of bleeding showed no significant difference. CONCLUSION: In this retrospective study performed in patients at high risk of postoperative bleeding, sugammadex at doses of 2 and 4 mg/kg was not associated with increased bleeding. This study, the first in this field, suggests that future prospective investigations should target patients receiving 4 or 16 mg/kg of sugammadex and/or with documented preoperative abnormal coagulations tests.

[Perioperative anaesthetic management of an epileptic patient treated with a vagus nerve stimulation]. / Gestion périopératoire d'un patient épileptique porteur d'une neurostimulation du nerf vague.

The vagal nerve stimulation is approved for medically refractory epilepsy and major depression. We report the perioperative management of an epileptic patient with this indwelling device. This observation summarizes the physiologic implications and the specific anaesthetic considerations for procedures with this pre-existing device.

[Impact of the hyperthermic intraperitoneal chemotherapy on the fluid-electrolytes changes and on the acid-base balance]. / Retentissements hydroélectrolytiques et acidobasiques de la chimiohyperthermie intrapéritonéale.

BACKGROUND: Hyperthermic intraperitoneal chemoperfusion (HIPEC) is an innovative treatment of the peritoneal carcinomatosis with potential iatrogenicity. This observational study was designed to improve our understanding of HIPEC's impact on the renal and respiratory functions, on temperature, blood cells counts, body fluids/electrolytes and acid-base balance. METHODS: We retrospectively analyzed the perioperative care of 20 patients that underwent HIPEC with oxaliplatin (n=19) and mitomycin C (n=1). The abdominal cavity was filled with the peritoneal dialysis fluid with dextrose 5%: volume of 2L/m(2). Follow-up for the study was stopped on postoperative day 7. RESULTS: The main changes were appearing just after the HIPEC procedure: increased diuresis, lactic acidosis, hyponatremia and hyperglycaemia (despite aggressive intravenous insulin therapy). In our series, there was no renal failure or impact on blood cells counts until the 7(th) day, neither some changes on the arterial blood gases. CONCLUSION: Hyperglycemia might explain increased diuresis of lactic acidosis and the rapid installation of hyponatremia. Taken together, these results suggest that glycemic control must be improved in order to avoid the other metabolic disturbances.

[Monitoring of neuromuscular block and prevention of residual paralysis]. / Monitorage de la curarisation et prévention de la curarisation résiduelle.

Neuromuscular monitoring and routine use of reversal agents are key elements in the prevention of residual paralysis. According to a nation-wide survey up to 52 % of anaesthesiologists in France apply regularly neuromuscular monitoring after a single intubating dose of a neuromuscular blocking agent and 74 % in case of repetitive administration. However, reversal is rather the exception than routine and, still according to this survey, the risk of residual paralysis largely underestimated. The development of a new class of reversal agents (cyclodextrins) may further modify the management of neuromuscular blockade in clinical practice. The article aims to revise the principles of neuromuscular monitoring and evaluate whether its use is still mandatory when sugammadex is used.

[Indications and clinical use of sugammadex]. / Indications et utilisation clinique du sugammadex.

Sugammadex, a cyclodextrin, is a novel agent designed to encapsulate selectively steroidal neuromuscular blocking agents such as rocuronium and vecuronium as well. One molecule of sugammadex is able to encapsulate only one molecule of muscle relaxant. This original pharmacological property allows a very rapid reversal of muscle paralysis. After sugammadex injection, a train of four ratio higher than 0.9 is obtained in less than 5 minutes in all the patients whatever the degree of muscle paralysis at the time of reversal and even when anesthesia is maintained with halogenated agents. However, in order to preserve this efficacy, the dose of sugammadex needs to be adjusted to the degree of muscle paralysis at the time of reversal : 2 mg/kg after obtaining 2 responses at the adductor pollicis muscle after a train of four stimulation, 4 mg/kg with a post-tetanic count between 1 and 3 responses, and 12 to 16 mg/kg in case of rescue reversal (3 to 15 minutes after 0.6 to 1.2 mg/kg rocuronium). Even if the original property of sugammadex lets us think that per-operative neuromuscular transmission monitoring would not be furthermore useful, the assessment of the exact degree of muscle paralysis before reversal is mandatory for choosing the right dose of sugammadex.

[Pharmacology of sugammadex]. / Pharmacologie du sugammadex.

Sugammadex is a new molecule derived from a known pharmacological class : the cyclodextrins known and used in human for many years. It was recently demonstrated that cyclodextrins could encapsulate and bind strongly steroidal neuromuscular blocking agents. Among cyclodextrins gamma-cyclodextrins proved to be more efficient. The binding of cyclodextrins to rocuronium and compound's water solubility was greatly improved by addition of 8 side chains to glycopyranoses units and the presence of a negative charge to the end of these side-chains. Animal studies have clearly demonstrated that sugammadex is faster in onset than anticholinesterase agents and is specific of steroidal neuromuscular blocking agents. It cannot reverse neuromuscular block induced by succinylcholine or benzylisoquinolines such as atracurium or cisatracurium. In human, the dose of sugammadex required to reverse shallow block is 2 mg/kg approximately whereas 4 mg/kg is needed to reverse deep level of neuromuscular block with a few responses at the post tetanic count at the adductor pollicis. The use of sugammadex was not associated with recurrence of block when an adequate dose was administered.

Monitoring neuromuscular block: an update.

The first part of this article presents an update of the basic considerations of neuromuscular monitoring. It emphasises the need to assure supramaximal stimulation, to place the stimulating electrodes correctly and to use appropriate sites for nerve stimulation as well as appropriate stimulation patterns. The second part focuses on current developments and ongoing discussion. The authors describe the performance of acceleromyography and the need for initial calibration when using these quantitative devices.

Serum troponin Ic values in organ donors are related to donor myocardial dysfunction but not to graft dysfunction or rejection in the recipients.

BACKGROUND: Increased plasma cardiac troponin I (cTnI) values in heart donors are associated with donor myocardial dysfunction and increased risk of rejection in the recipients. We investigated the association between cTnI values and myocardial dysfunction in potential heart donors and the relationship between donors' cTnI values and recipients' early myocardial function and 1 year survival and risk of rejection. METHODS: cTnI was measured in 159 consecutive potential heart donors. Myocardial function was estimated by the left ventricular ejection fraction (LVEF) and segmental wall motion abnormalities (SWMA). Results are mean+/-SD (range) or median (interquartile range). RESULTS: cTnI values in potential donors were 2.1+/-5 ng/ml (0-40.4 ng/ml); cTnI values were significantly (P<0.001) higher: 4.2+/-5.9 ng/ml (0-30.6 ng/ml) for potential donors with LVEF <50% versus LVEF >50%: 1.7+/-4.7 ng/ml (0-40.4 ng/ml). cTnI values were significantly lower for donors without SWMA. cTnI values were significantly (P<0.001) lower for the 90 donors whose hearts were harvested: 1.1+/-2.3 ng/ml (0-15.6 ng/ml) versus the not harvested: 3.6+/-6.9 ng/ml (0-40.4 ng/ml). There were 87 recipients followed for 1 year. Donors' cTnI values were not associated with early alteration of LVEF, incidence of rejection or 1 year recipients' survival. CONCLUSION: Increased cTnI values in potential heart donors are statistically associated with myocardial dysfunction and could be helpful for organ selection. In contrast, cTnI values in heart donors were not associated with graft dysfunction or recipient survival after transplantation.

Reversal of rocuronium-induced neuromuscular block with sugammadex is faster than reversal of cisatracurium-induced block with neostigmine.

BACKGROUND: Reversal of the residual effect of rocuronium or cisatracurium by neostigmine may be slow and associated with side-effects. This randomized, safety-assessor-blinded study compared the efficacy of sugammadex, a selective relaxant binding agent for reversal of rocuronium-induced neuromuscular block, with that of neostigmine for reversal of cisatracurium-induced neuromuscular block. The safety of sugammadex and neostigmine was also evaluated. METHODS: Adult surgical patients (ASA class I-III) were randomized to sugammadex 2.0 mg kg(-1) for reversal of block induced by rocuronium 0.6 mg kg(-1), or neostigmine 50 microg kg(-1) for reversal of block induced by cisatracurium 0.15 mg kg(-1). Anaesthesia was induced and maintained using i.v. propofol and remifentanil, fentanyl, or sufentanil. Neuromuscular function was monitored using acceleromyography (TOF-Watch SX). Sugammadex or neostigmine was administered at reappearance of T(2). The primary efficacy variable was time for recovery of the train-of-four (TOF) ratio to 0.9. RESULTS: Eighty-four patients were randomized, 73 of whom received sugammadex (n=34) or neostigmine (n=39). Time from start of administration of reversal agent to recovery of the TOF ratio to 0.9 was 4.7 times faster with sugammadex than with neostigmine (geometric mean=1.9 vs 9.0 min, P<0.0001). Reversal of block was sustained in all patients. There were no serious adverse effects from either reversal agent and no significant changes in any measure of safety, except for similar elevations in urinary N-acetyl glucosaminidase in both groups. CONCLUSIONS: Sugammadex 2.0 mg kg(-1) administered at reappearance of T(2) was significantly faster in reversing rocuronium-induced blockade than neostigmine was in reversing cisatracurium-induced block.

Relationship between procalcitonin values and infection in brain-dead organ donors.

BACKGROUND AND AIMS: An association between the inflammatory reactions estimated by several biomarkers and organ dysfunction has been reported in brain-dead organ donors (BDOD). Procalcitonin (PCT), a biomarker of inflammation due to bacterial infection, is increased among BDOD. However, is not known whether infection changes PCT values in BDOD. MATERIALS AND METHODS: We retrospectively analyzed 82 BDOD including several demographic and clinical parameters, bacterial culture results, antibiotics prescription, and plasma values of PCT measured before organ harvesting. Infection was diagnosed to be either a positive bacterial culture (restricted definition) and/or prescription of antibiotics (extended definition). RESULTS: The median PCT value was 1.5 (interquartile range [IQR], 0.4 to 6.9; range, 0 to 526 ng/mL; n=82). Thirty-eight (46%) and 24 (29%) patients had PCT values>2 ng/mL and >5 ng/mL, respectively. Median PCT values among infected (1.18; IQR, 0.27 to 6.55 ng/mL) versus noninfected (1.57; IQR, 0.53 to 7.15 ng/mL) BDOD (restricted definition) were not different (P=.36). The area under the receiver operating characteristic curve using PCT to predict infection (restricted definition) was 0.52. Specificity of PCT to predict infection was above 80% at PCT values>9 ng/mL. CONCLUSION: Our results confirmed PCT values are increased in BDOD, suggesting that this was not related to an infectious cause (whatever definition was used) unless PCT values are high.

Sequential measurements of troponin Ic values in brain-dead patients considered as potential heart donors.

It was suggested that a single value of normal or increased plasma cardiac troponin T or I (cTnT or cTnI) concentration could contribute to estimate donor myocardial damage and function in brain-dead patients. In patients with acute coronary syndromes, an initial normal value of troponin must be confirmed several hours later but no such recommendations exist for brain-dead patients. We investigated the relationship between two sequential (6 h interval) measurements of plasma cTnI concentrations in brain-dead patients considered as potential heart donors. The first and the second TnIc values were correlated with an adjusted r2 value of 0.92 (p<0.001). Our results suggest therefore that it is not necessary to repeat the measurements, when the value of plasma cTnI concentration is taken into consideration in the algorithm for cardiac harvesting.