N-Acetylcysteine to Reduce Mortality for Patients Requiring Cardiac Catheterization or Cardiac Surgery: A Systematic Review and Meta-analysis.

ABSTRACT: Multimers of von Willebrand factor play a critical role in various processes inducing morbidity and mortality in cardiovascular-risk patients. With the ability to reduce von Willebrand factor multimers, N-acetylcysteine (NAC) could reduce mortality in patients undergoing coronary catheterization or cardiac surgery. However, its impact in perioperative period has never been studied so far in regard of its potential cardiovascular benefits. Then, 4 databases were searched for randomized controlled trials that compared in-hospital mortality between an experimental group, with NAC, and a control group without NAC, in patients undergoing coronary catheterization or cardiac surgery. The primary efficacy outcome was in-hospital mortality. Secondary outcomes were the occurrence of thrombotic events, major cardiovascular events, myocardial infarction, and contrast-induced nephropathy. The safety outcome was occurrence of hemorrhagic events. Nineteen studies totaling 3718 patients were included. Pooled analysis demonstrated a reduction of in-hospital mortality associated with NAC: odds ratio, 0.60; 95% confidence interval, 0.39-0.92; P = 0.02. The occurrence of secondary outcomes was not significantly reduced with NAC except for contrast-induced nephropathy. No difference was reported for hemorrhagic events. Subgroup analyses revealed a life-saving effect of NAC in a dose-dependent manner with reduction of in-hospital mortality for the NAC high-dose group, but not for the NAC standard-dose (<3500-mg) group. In conclusion, without being able to conclude on the nature of the mechanism involved, our review suggests a benefit of NAC in cardiovascular-risk patients in perioperative period in terms of mortality and supports prospective confirmatory studies.

Comparison of the modified Mallampati classification score versus the best visible Mallampati score in the prediction of difficult tracheal intubation: a single-centre prospective observational study.

PURPOSE: The modified Mallampati classification is part of the preoperative airway risk assessment. Inconsistency in the way it is examined may contribute to heterogeneity in its diagnostic performance. The best visible Mallampati score could reduce interobserver heterogeneity but its diagnostic characteristics remain unknown. METHODS: During preoperative anesthesia consultation of adult patients with a senior anesthesiologist, we compared the modified Mallampati classification score vs the best visible Mallampati score using cervical extension, tongue in, and phonation. The primary outcome was the diagnostic characteristic of the modified Mallampati classification score vs the best visible Mallampati score as predictors of difficult orotracheal intubation (more than two direct laryngoscopies or need for an alternate device). We performed a multivariable analysis to identify independent predictors of difficult orotracheal intubation in the tested cohort. RESULTS: Difficult orotracheal intubation occurred in 77/3,243 (2.4%) patients. A best visible Mallampati score was obtained in 1,596 (49.2%) patients. Sensitivity and specificity of the modified Mallampati classification score for predicting difficult orotracheal intubation were 0.56 (95% confidence interval [CI], 0.44 to 0.66) and 0.69 (95% CI, 0.68 to 0.71), respectively. By comparison, the best visible Mallampati score was less sensitive (difference, -0.30; 95% CI, -0.19 to -0.30; P < 0.001) but more specific (difference, 0.24; 95% CI, 0.22 to -0.25; P < 0.001). In patients with difficult orotracheal intubation, 53% were incorrectly reclassified as low risk by the best visible Mallampati score. CONCLUSION: Compared with the modified Mallampati classification score, the best visible Mallampati score decreased sensitivity for predicting difficult orotracheal intubation and falsely classified half of the patients with difficult orotracheal intubation. Taking the risks associated with difficult airways into account, our findings indicate that a careful examination of the modified Mallampati classification is required during the global preoperative airway examination. STUDY REGISTRATION: ClinicalTrials.gov ( NCT02788253 ); 9 February 2016.

RéSUMé: OBJECTIF: La classification de Mallampati modifiée fait partie de l'évaluation préopératoire des risques pour les voies aériennes. La disparité dans la façon dont elle est examinée peut contribuer à l'hétérogénéité de ses performances diagnostiques. Le meilleur score de Mallampati visible pourrait réduire l'hétérogénéité inter-observateurs, mais ses caractéristiques diagnostiques restent inconnues. MéTHODE: Lors de la consultation d'anesthésie préopératoire de patient·es adultes avec un·e anesthésiologiste senior, nous avons comparé le score de classification sur l'échelle de Mallampati modifiée vs le meilleur score de Mallampati visible en utilisant l'extension cervicale, la langue rentrée, et la phonation. Le critère d'évaluation principal était la caractéristique diagnostique du score modifié de classification de Mallampati vs le meilleur score de Mallampati visible comme prédicteurs d'une intubation orotrachéale difficile (plus de deux laryngoscopies directes ou nécessité d'un autre dispositif). Nous avons réalisé une analyse multivariée pour identifier les prédicteurs indépendants d'intubation orotrachéale difficile dans la cohorte testée. RéSULTATS: Une intubation orotrachéale difficile est survenue chez 77 patient·es sur 3243 (2,4 %). Le meilleur score de Mallampati visible a été obtenu chez 1596 patient·es (49,2 %). La sensibilité et la spécificité du score de classification de Mallampati modifié pour prédire l'intubation orotrachéale difficile étaient de 0,56 (intervalle de confiance [IC] à 95 %, 0,44 à 0,66) et 0,69 (IC 95 %, 0,68 à 0,71), respectivement. À titre de comparaison, le score de Mallampati le plus visible était moins sensible (différence, −0,30; IC 95 %, −0,19 à −0,30; P < 0,001) mais plus spécifique (différence, 0,24; IC 95 %, 0,22 à −0,25; P < 0,001). Chez les patient·es présentant une intubation orotrachéale difficile, 53 % ont été reclassé·es à tort comme à faible risque par le score de Mallampati le plus visible. CONCLUSION: Par rapport au score modifié de classification de Mallampati, le score de Mallampati le mieux visible a diminué la sensibilité pour prédire l'intubation orotrachéale difficile et a faussement classé la moitié des patient·es présentant une intubation orotrachéale difficile. En tenant compte des risques associés aux voies aériennes difficiles, nos résultats indiquent qu'un examen minutieux de la classification de Mallampati modifiée est nécessaire lors de l'examen préopératoire global des voies aériennes. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov ( NCT02788253 ); 9 février 2016.

Change in stroke volume during alveolar recruitment maneuvers through transient continuous positive airway pressure or stepwise increase in positive end expiratory pressure in anesthetized patients: a prospective randomized double-blind study.

PURPOSE: Intraoperative alveolar recruitment maneuvers (ARM) used during protective ventilation strategy may have severe adverse hemodynamic effects, reported mainly during abrupt continuous positive airway pressure (CPAP). Stepwise increase and decrease in positive end expiratory pressure (PEEP) may be used. We compared the hemodynamic effects of these two maneuvers. METHODS: We enrolled patients scheduled for intermediate to high-risk surgery with continuous arterial pressure and stroke volume (esophageal Doppler) monitoring in a prospective, single-centre, randomized, double-blind study. After induction of anesthesia, we ensured preload independence of stroke volume before an ARM was randomly performed: 30 cm H2O CPAP for 30 sec (CPAP group) or stepwise increase in PEEP from 8 to 20 cm H2O with inspiratory pressure of 10 cm H2O followed by a stepwise decrease in PEEP from 20 to 8 cm H2O (STEP group). The primary outcome was the relative variation in stroke volume. RESULTS: Thirty-five patients were included in the CPAP and STEP groups. Mean (standard deviation) relative variation in stroke volume was -57 (24)% in the CPAP group and -32 (24)% in the STEP group (difference, -25; 95% confidence interval, -37 to -14; P < 0.001). Changes in systolic, mean, and diastolic arterial pressure over time were not different between groups. The ARM was stopped because of a systolic arterial pressure < 70 mm Hg in four patients in the CPAP group and in one patient in the STEP group. CONCLUSIONS: Alveolar recruitment maneuvers through stepwise increase and decrease in PEEP have a better hemodynamic tolerance than transient CPAP. TRIAL REGISTRATION: ClinicalTrials.gov (NCT04802421); first submitted 15 March 2021.

RéSUMé: OBJECTIF: Les manœuvres de recrutement alvéolaire (MRA) peropératoire utilisées pendant les stratégies de ventilation protectrice peuvent avoir des effets hémodynamiques indésirables graves, rapportés principalement lors d'une ventilation en pression positive continue (PPC ou CPAP en anglais) abrupte. L'augmentation et la diminution par étapes de la pression expiratoire positive (PEP) peuvent être utilisées. Nous avons comparé les effets hémodynamiques de ces deux manœuvres. MéTHODE: Nous avons recruté des patient·es devant bénéficier d'une chirurgie à risque intermédiaire à élevé avec monitorage continu de la tension artérielle et du volume d'éjection (Doppler œsophagien) dans le cadre d'une étude prospective, monocentrique, randomisée et à double insu. Après induction de l'anesthésie, nous nous sommes assurés de l'indépendance de précharge du volume d'éjection avant qu'une MRA ne soit effectuée au hasard : 30 cm H2O PPC pendant 30 secondes (groupe PPC) ou augmentation progressive de la PEP de 8 à 20 cm H2O avec pression inspiratoire de 10 cm H2O, suivie d'une diminution progressive de la PEP de 20 à 8 cm H2O (groupe STEP). Le critère d'évaluation principal était la variation relative du volume d'éjection. RéSULTATS: Trente-cinq personnes ont été incluses dans les groupes PPC et STEP. La variation relative moyenne (écart type) du volume d'éjection était de −57 (24) % dans le groupe PPC et de −32 (24) % dans le groupe STEP (différence, −25; intervalle de confiance à 95 %, −37 à −14; P < 0,001). Les changements dans la tension artérielle systolique, moyenne et diastolique au fil du temps n'étaient pas différents entre les groupes. Les MRA ont été arrêtées en raison d'une tension artérielle systolique < 70 mm Hg chez quatre patient·es du groupe PPC et chez une personne du groupe STEP. CONCLUSION: Les manœuvres de recrutement alvéolaire par augmentation et diminution par étapes de la PEP ont une meilleure tolérance hémodynamique que la PPC transitoire. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT04802421); soumis pour la première fois le 15 mars 2021.

Development by "simple consensus" of a tool to assist the activation of the helicopter at SAMU 14 / Élaboration par méthode du consensus simple d'un outil d'aide au déclenchement d'un hélicoptère au SAMU 14

The main objective of this work was to develop a tool to assist the activation of a helicopter emergency medical service (HEMS) for the SAMU 14. We opted for a methodology based on "guidelines of good professional practice." Simple consensus was used. A multidisciplinary working group (pilots, medical regulation assistants, doctors) was created. Subgroup meetings (pilots, medical regulation assistants, doctors) developed subparts of the tool. The assembly of the tool's subparts was reviewed by the working group and then by an independent reading group. This work enabled the consensual creation of a tool to support the use of the helicopter emergency medical service (HEMS) for the SAMU 14. It is composed of maps, a protocol, and a written procedure of activation. This methodology by "simple consensus" allowed the development of a tool rationalizing the activation of the helicopter emergency medical service (HEMS) for the SAMU 14. It was the first work of this type within the SAMU 14. This simple and transposable methodology could be used in other emergency centers or for other multidisciplinary protocols.

L'objectif principal de ce travail était la création d'un outil d'aide au déclenchement d'un SMUR héliporté au SAMU 14. Nous avons opté pour une méthodologie type « recommandations de bonnes pratiques professionnelles ¼ (RBPP). Le consensus simple a été utilisé. Un groupe de travail multidisciplinaire (pilotes, assistant de régulation médicale [ARM], médecins) a été créé. Des réunions en sous-groupe (pilote, ARM et médecins) ont permis d'élaborer des sous-parties de l'outil. L'assemblage des sous-parties de l'outil a été relu par le groupe de travail puis par un groupe de lecture autonome et validé en réunion de service. Ce travail a permis la création consensuelle d'un outil d'aide à l'emploi du vecteur héliporté en SMUR primaire au sein du SAMU 14. Il est composé de cartes, d'une fiche réflexe et d'une procédure écrite de déclenchement. Cette méthodologie par consensus simple a permis la création d'un outil rationalisant le déclenchement du vecteur héliporté pour le SAMU 14. Il s'agissait du premier travail de ce type au SAMU 14. Cette méthodologie simple et transposable pourrait être utilisée dans d'autres centres 15 ou pour d'autres protocoles multidisciplinaires.

Safety of perioperative intravenous lidocaine in liver surgery - A pilot study.

Background and Aims: Perioperative lidocaine infusion has many interesting properties such as analgesic effects in the context of enhanced recovery after surgery. However, its use is limited in liver surgery due to its hepatic metabolism. Material and Methods: This prospective, monocentric study was conducted from 2020 to 2021. Patients undergoing liver surgery were included. They received a lidocaine infusion protocol until the beginning of hepatic transection (bolus dose of 1.5 mg kg-1, then a continuous infusion of 2 mg kg-1 h-1). Plasma concentrations of lidocaine were measured four times during and after lidocaine infusion. Results: Twenty subjects who underwent liver resection were analyzed. There was 35% of preexisting liver disease before tumor diagnosis, and 75% of liver resection was defined as "major hepatectomy." Plasmatic levels of lidocaine were in the therapeutic range. No blood sample showed a concentration above the toxicity threshold: 1.6 (1.3-2.1) µg ml-1 one hour after the start of infusion, 2.5 (1.7-2.8) µg ml-1 at the end of hepatic transection, 1.7 (1.3-2.0) µg ml-1 one hour after the end of infusion, and 1.2 (0.8-1.4) µg ml-1 at the end of surgery. Comparative analysis between the presence of a preexisting liver disease or not and the association of intraoperative vascular clamping or not did not show significant difference concerning lidocaine blood levels. Conclusion: Perioperative lidocaine infusion seems safe in the field of liver surgery. Nevertheless, additional prospective studies need to assess the clinical usefulness in terms of analgesia and antitumoral effects.

Consequences of General Anesthesia in Infancy on Behavior and Brain Structure.

BACKGROUND: One in 7 children will need general anesthesia (GA) before the age of 3. Brain toxicity of anesthetics is controversial. Our objective was to clarify whether exposure of GA to the developing brain could lead to lasting behavioral and structural brain changes. METHODS: A first study was performed in mice. The behaviors (fear conditioning, Y-maze, and actimetry) and brain anatomy (high-resolution magnetic resonance imaging) of 6- to 8-week-old Swiss mice exposed or not exposed to GA from 4 to 10 days old were evaluated. A second study was a complementary analysis from the preexisting APprentissages EXécutifs et cerveau chez les enfants d'âge scolaire (APEX) cohort to assess the replicability of our data in humans. The behaviors (behavior rating inventory of executive function, emotional control, and working memory score, Backward Digit Span, and Raven 36) and brain anatomy (high-resolution magnetic resonance imaging) were compared in 102 children 9 to 10 years of age exposed or not exposed to a single GA (surgery) during infancy. RESULTS: The animal study revealed chronic exacerbated fear behavior in the adult mice (95% confidence interval [CI], 4-80; P = .03) exposed to postnatal GA; this was associated with an 11% (95% CI, 7.5-14.5) reduction of the periaqueductal gray matter (P = .046). The study in humans suggested lower emotional control (95% CI, 0.33-9.10; P = .06) and a 6.1% (95% CI, 4.3-7.8) reduction in the posterior part of the right inferior frontal gyrus (P = .019) in the children who had been exposed to a single GA procedure. CONCLUSIONS: The preclinical and clinical findings of these independent studies suggest lasting effects of early life exposure to anesthetics on later emotional control behaviors and brain structures.

Evaluation of quality of care in neonatal anesthesia using a bundle of intraoperative parameters.

BACKGROUND: Maintenance of physiological homeostasis is key in the safe conduct of pediatric anesthesia. Achieving this goal is especially difficult in neonatal surgery. AIMS: The first aim was to document the absolute number of seven intraoperative parameters monitored during anesthesia in neonates undergoing gastroschisis surgery. The second aims were to determine the frequency of monitoring of each of these intraoperative parameters as well as the proportion of cases in which each parameter was both monitored and maintained within a pre-defined range. METHODS: This retrospective observational analysis includes data from 53 gastroschisis surgeries performed at Caen University Hospital (2009-2020). Seven intraoperative parameters were analyzed. First, we assessed if the intraoperative parameters were monitored or not. Second, when monitored, we assessed if these parameters were maintained within a pre-defined range, based on the current literature and on local agreement. RESULTS: The median [first-third Q], range (min-max) number of intraoperative parameters monitored during the 53 gastroschisis surgeries was 6 [5-6], range (4-7). There were no missing data for the automatically recorded ones such as arterial blood pressure, heart rate, end-tidal CO2, and oxygen saturation. Temperature was monitored in 38% of the patients, glycemia in 66%, and natremia in 68% of the cases. Oxygen saturation and heart rate were maintained within the pre-defined range in 96% and 81% of the cases respectively. The blood pressure (28%) and temperature (30%) were instead the least often maintained within the pre-defined range. CONCLUSION: Although a median of six out of the seven selected intraoperative parameters were monitored during gastroschisis repair, only two of them (oxygen saturation and heart rate) were maintained within the pre-defined range more than 80% of the time. It might be of interest to extend physiologic age- and procedure-based approach to the development of specific preoperative anesthetic planning.

Élaboration par méthode du consensus simple d'un outil d'aide au déclenchement d'un hélicoptère au SAMU 14.

The main objective of this work was to develop a tool to assist the activation of a helicopter emergency medical service (HEMS) for the SAMU 14. We opted for a methodology based on "guidelines of good professional practice." Simple consensus was used. A multidisciplinary working group (pilots, medical regulation assistants, doctors) was created. Subgroup meetings (pilots, medical regulation assistants, doctors) developed subparts of the tool. The assembly of the tool's subparts was reviewed by the working group and then by an independent reading group. This work enabled the consensual creation of a tool to support the use of the helicopter emergency medical service (HEMS) for the SAMU 14. It is composed of maps, a protocol, and a written procedure of activation. This methodology by "simple consensus" allowed the development of a tool rationalizing the activation of the helicopter emergency medical service (HEMS) for the SAMU 14. It was the first work of this type within the SAMU 14. This simple and transposable methodology could be used in other emergency centers or for other multidisciplinary protocols.

Individualised or liberal red blood cell transfusion after cardiac surgery: a randomised controlled trial.

BACKGROUND: Current practice guidelines for red blood cell (RBC) transfusion in ICUs are based on haemoglobin threshold, without consideration of oxygen delivery or consumption. We aimed to evaluate an individual physiological threshold-guided by central venous oxygen saturation ScvO2. METHODS: In a randomised study in two French academic hospitals, 164 patients who were admitted to ICU after cardiac surgery with postoperative haemoglobin <9 g dl-1 were randomised to receive a transfusion with one unit of RBCs (haemoglobin group) or transfusion only if the ScvO2 was <70% (individualised group). The primary outcome was the number of subjects receiving at least one unit of RBCs. The secondary composite outcome was acute kidney injury, stroke, myocardial infarction, acute heart failure, mesenteric ischaemia, or in-hospital mortality. One- and 6-month mortality were evaluated during follow-up. RESULTS: The primary outcome was observed for 80 of 80 subjects (100%) in the haemoglobin group and in 61 of 77 patients (79%) in the individualised group (absolute risk -21% [-32.0; -14.0]; P<0.001). There was no significant difference in the secondary outcome between the two groups. Follow-up showed a non-significant difference in mortality at 1 and 6 months. CONCLUSIONS: An individualised strategy based on an central venous oxygen saturation threshold of 70% allows for a more restrictive red blood cell transfusion strategy with no incidence on postoperative morbidity or 6-month mortality. CLINICAL TRIAL REGISTRATION: NCT02963883.

Withholding and withdrawal of life-sustaining therapy in 8569 trauma patients: A multicentre, analytical registry study.

BACKGROUND: This study aimed to determine the prevalence of withholding or withdrawal of life-sustaining therapy (WLST) decisions in trauma ICU patients, using a large registry. We hypothesised that this prevalence is similar to that of the general population admitted to an ICU. As secondary aims, it sought to describe the trauma patients for whom the decision was made for WLST and the factors associated with this decision. DESIGN: This observational study assessed data from 14 French centres listed in the TraumaBaseTM registry. All trauma patients hospitalised for more than 48 h were pro-spectively included. RESULTS: Data from 8569 trauma patients, obtained from January 2016 to December 2018, were included in this study. A WLST decision was made in 6% of all cases. In the WLST group, 67% of the patients were older men (age: 62 versus 36, P  < 0.001); more often they had a prior medical history and higher median severity scores than the patients in the no WLST decision group; SAPS II 58 (46 to 69) versus 21 (13 to 35) and ISS 26 (22 to 24) versus 12 (5 to 22), P  < 0.001. Neurological status was strongly associated with WLST decisions. The geographic area of the ICUs affected the rate of the WLST decisions. The ICU mortality was 11% (n = 907) of which 47% (n = 422) were preceded by WLST decisions. Fourteen percent of WLST orders were not associated to the death. CONCLUSION: Among 8569 patients, medical history, trauma severity criteria, notably neurological status and geographical areas were associated with WLST. These regional differences deserve to be investigated in future studies.

Individualized Fluid Management Using the Pleth Variability Index: A Randomized Clinical Trial.

BACKGROUND: The present trial was designed to assess whether individualized strategies of fluid administration using a noninvasive plethysmographic variability index could reduce the postoperative hospital length of stay and morbidity after intermediate-risk surgery. METHODS: This was a multicenter, randomized, nonblinded parallel-group clinical trial conducted in five hospitals. Adult patients in sinus rhythm having elective orthopedic surgery (knee or hip arthroplasty) under general anesthesia were enrolled. Individualized hemodynamic management aimed to achieve a plethysmographic variability index under 13%, and the standard management strategy aimed to maintain a mean arterial pressure above 65 mmHg during general anesthesia. The primary outcome was the postoperative hospital length of stay decided by surgeons blinded to the group allocation of the patient. RESULTS: In total, 447 patients were randomized, and 438 were included in the analysis. The mean hospital length of stay ± SD was 6 ± 3 days for the plethysmographic variability index group and 6 ± 3 days for the control group (adjusted difference, 0.0 days; 95% CI, -0.6 to 0.5; P = 0.860); the theoretical postoperative hospital length of stay was 4 ± 2 days for the plethysmographic variability index group and 4 ± 1 days for the control group (P = 0.238). In the plethysmographic variability index and control groups, serious postoperative cardiac complications occurred in 3 of 217 (1%) and 2 of 224 (1%) patients (P = 0.681), acute postoperative renal failure occurred in 9 (4%) and 8 (4%) patients (P = 0.808), the troponin Ic concentration was more than 0.06 µg/l within 5 days postoperatively for 6 (3%) and 5 (2%) patients (P = 0.768), and the postoperative arterial lactate measurements were 1.44 ± 1.01 and 1.43 ± 0.95 mmol/l (P = 0.974), respectively. CONCLUSIONS: Among intermediate-risk patients having orthopedic surgery with general anesthesia, fluid administration guided by the plethysmographic variability index did not shorten the duration of hospitalization or reduce complications.

Effect of Oral Carbohydrate Intake During Labor on the Rate of Instrumental Vaginal Delivery: A Multicenter, Randomized Controlled Trial.

BACKGROUND: Carbohydrate intake during physical exercise improves muscle performance and decreases fatigue. We hypothesized that carbohydrate intake during labor, which is a period of significant physical activity, can decrease the instrumental vaginal delivery rate. METHODS: In a multicenter, prospective, randomized, controlled trial, healthy adult pregnant women presenting with spontaneous labor were assigned to a "Carbohydrate" group (advised to drink 200 mL of apple or grape juice without pulp every 3 hours) or a "Fasting" group (water only). The primary outcome was the instrumental vaginal delivery rate. Secondary outcomes included duration of labor, rate of cesarean delivery, evaluation of maternal hunger, thirst, stress, fatigue, and overall feeling during labor by numeric rating scale (0 worst rating to 10 best rating), rate of vomiting, and hospital length of stay. Statistical analysis was performed on an intention-to-treat basis. The primary outcome was tested with the "Fasting" group as the reference group. The P values for secondary outcomes were adjusted for multiple comparisons. The differences between groups are reported with 99% confidence interval (CI). RESULTS: A total of 3984 women were analyzed (2014 in the Carbohydrate group and 1970 in the Fasting group). There was no difference in the rate of instrumental delivery between the Carbohydrate (21.0%) and the Fasting (22.4%) groups (difference, -1.4%; 99% CI, -4.9 to 2.2). No differences were found between the Carbohydrate and the Fasting groups for the duration of labor (difference, -7 minutes; 99% CI, -25 to 11), the rate of cesarean delivery (difference, -0.3%; 99% CI, -2.4 to 3.0), the rate of vomiting (difference, 2.8%; 99% CI, 0.2-5.7), the degree of self-reported fatigue (difference, 1; 99% CI, 0-2), self-reported hunger (difference, 0; 99% CI, -1 to 1), thirst (difference, 0; 99% CI, -1 to 1), stress (difference, 0; 99% CI, -1 to 1), overall feeling (difference, 0; 99% CI, 0-0), and the length of hospitalization (difference, 0; 99% CI, -1 to 0). CONCLUSIONS: Carbohydrate intake during labor did not modify the rate of instrumental vaginal delivery.

Comparison of pre-oxygenation using spontaneous breathing through face mask and high-flow nasal oxygen: A randomised controlled crossover study in healthy volunteers.

BACKGROUND: High-flow nasal oxygen (HFNO) therapy has been proposed for pre-oxygenation before intubation, but the end-tidal fraction of oxygen (ETO2) obtained remains unknown. OBJECTIVE(S): To compare the ETO2 following a 3 min pre-oxygenation with HFNO and face mask. SETTING: Operating room in a primary university hospital. DESIGN: A randomised crossover study. PARTICIPANTS: Fifty healthy volunteers. INTERVENTIONS: Participants were randomly pre-oxygenated through spontaneous breathing 100% oxygen in a face mask and with HFNO (mouth closed, heated and humidified gas flow at 60 l min). In the face mask group, the ETO2 was measured continuously. In the HFNO group, the nasal cannula was quickly exchanged with a face mask while the subject held their breath at end inspiration and the ETO2 was measured after a deep expiration. The protocol ended when ETO2 reached 90% or otherwise at 6 min. MAIN OUTCOME MEASURES: The primary endpoint was the ETO2 after 3 min of pre-oxygenation. Secondary endpoints were the proportion of participants with an ETO2 at least 90% and the time until the ETO2 at least 90%. RESULTS: The ETO2 after 3 min of pre-oxygenation was 89 (2) % and 77 (12) % in the face mask and HFNO groups [difference 12% (95% confidence interval, 95% CI: 8 to 15]; P < 0.001), respectively. After 3 min of pre-oxygenation, 54 and 4% (P < 0.001) of volunteers had an ETO2 at least 90% in the face-mask and HFNO groups, respectively. After 6 min of pre-oxygenation, 96 and 46% (P < 0.001) of volunteers had an ETO2 at least 90% in the face-mask and HFNO groups, respectively. In the face mask group, the hazard ratio to achieve an ETO2 of 90% was 5.3 (95% CI: 3.2 to 8.9; P < 0.001). CONCLUSION: Our study demonstrates that pre-oxygenation with HFNO is not a reliable method of pre-oxygenation before the induction of anaesthesia. TRIAL REGISTRATION: clinical trial NCT03399695.

Changes in stroke volume during an alveolar recruitment maneuvers through a stepwise increase in positive end expiratory pressure and transient continuous positive airway pressure in anesthetized patients. A prospective observational pilot study.

BACKGROUND AND AIMS: Recruitment maneuvers may be used during anesthesia as part of perioperative protective ventilation strategy. However, the hemodynamic effect of recruitment maneuvers remain poorly documented in this setting. MATERIAL AND METHODS: This was a prospective observational study performed in operating theatre including patients scheduled for major vascular surgery. Patients were monitored with invasive arterial pressure and esophageal doppler. After induction of general anesthesia, before surgery began, preload optimization based on stroke volume (SV) variation following fluid challenge was performed. Then, an alveolar recruitment maneuver (ARM) through stepwise increase in positive end expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) was performed. Hemodynamic data were noted before, during, and after the alveolar recruitment maneuver. RESULTS: ARM through stepwise increase in PEEP and CPAP were applied in 22 and 14 preload independent patients, respectively. Relative changes in SV during ARMs were significantly greater in the ARMCPAP group (-39 ± 20%) as compared to the ARMPEEP group (-15 ± 22%; P = 0.002). The difference (95% CI) in relative decrease in SV between ARMCPAP and ARMPEEP groups was -24% (-38 to -9; P = 0.001). Changes in arterial pressure, cardiac index, pulse pressure variation, peak velocity, and corrected flow time measures were not different between groups. CONCLUSION: During anesthesia, in preload independent patients, ARMs through CPAP resulted in a significantly greater decrease in SV than stepwise increase in PEEP. During anesthesia, ARM should be used cautiously.

Comparison of the Mallampati Classification in Sitting and Supine Position to Predict Difficult Tracheal Intubation: A Prospective Observational Cohort Study.

BACKGROUND: The Mallampati classification (MLPT) is normally evaluated in the sitting position. However, many patients cannot be evaluated in the sitting position for medical reasons. Thus, we compared the MLPT in sitting and supine positions in predicting difficult tracheal intubation (DTI). We hypothesized that the diagnostic accuracy of the MLPT performed in sitting and supine positions would differ. METHODS: We performed a single-center prospective observational study in adult patients who received general anesthesia and orotracheal intubation for noncardiac surgery. During the preanesthesia consultation, the MLPT in the sitting position was recorded. The day of surgery, the MLPT in the supine position and the difficulty of intubation (DTI) were recorded by an independent observer. The diagnostic performance of the MLPT for the prediction of DTI was evaluated in the sitting and supine positions through the area under the receiver operating characteristic (ROC) curve. The performance of the Naguib score in predicting DTI was calculated with the MLPT in sitting and supine positions. RESULTS: Among the 3036 patients, 157 (5.1%) had DTI. The area under the ROC curve for the MLPT in supine position (0.82 [0.78-0.84]) was greater than that for the MLPT in the sitting position (0.70 [0.66-0.75]; P < .001). The relationship between the sitting and supine MLPTs was moderate (Spearman rank correlation coefficient: 0.50; P < .001). The area under ROC curve for predicting DTI by the Naguib score calculated with the supine MLPT (0.78 [95% confidence interval, 0.74-0.82]) was greater than that for the Naguib score calculated with MLPT in the sitting position (0.69 [95% confidence interval, 0.63-0.74)]; P < .001). CONCLUSIONS: The MLPT performed in the supine position is possibly superior to that performed in the sitting position for predicting difficult intubation in adults.

Assessment of changes in blood glucose concentration with intravascular microdialysis.

Blood glucose and its variability of is a major prognostic factor associated with morbidity. We hypothesized that intravenous microdialysis incorporated in a central venous catheter (CVC) would be interchangeable with changes in blood glucose measured by the reference method using a blood gas analyzer. Microdialysis and central venous blood glucose measurements were simultaneously recorded in high-risk cardiac surgical patients. The correlation between absolute values was determined by linear regression and the Bland-Altman test for repeated measurements was used to compare bias, precision, and limits of agreement. Changes in blood glucose measurement were evaluated by four-quadrant plot and trend interchangeability methods (TIM). In the 23 patients analyzed, the CVC was used as part of standard care with no complications. The correlation coefficient for absolute values (N = 99) was R = 0.91 (P < 0.001). The bias, precision and limits of agreement were - 9.1, 17.4 and - 43.2 to 24.9 mg/dL, respectively. The concordance rate for changes in blood glucose measurements (N = 77) was 85% with the four-quadrant plot. The TIM showed that 14 (18%) changes of blood glucose measurements were uninterpretable. Among the remaining 63 (82%) interpretable changes, 23 (37%) were interchangeable, 13 (20%) were in the gray zone, and 27 (43%) were not interchangeable. Microdialysis using a CVC appears to provide imprecise absolute blood glucose values with risk of insulin misuse. Moreover, only one third of changes in blood glucose measurements were interchangeable with the reference method using the TIM.

Sodium Bicarbonate Versus Sodium Chloride for Preventing Contrast-Associated Acute Kidney Injury in Critically Ill Patients: A Randomized Controlled Trial.

OBJECTIVES: To test whether hydration with bicarbonate rather than isotonic sodium chloride reduces the risk of contrast-associated acute kidney injury in critically ill patients. DESIGN: Prospective, double-blind, multicenter, randomized controlled study. SETTING: Three French ICUs. PATIENTS: Critically ill patients with stable renal function (n = 307) who received intravascular contrast media. INTERVENTIONS: Hydration with 0.9% sodium chloride or 1.4% sodium bicarbonate administered with the same infusion protocol: 3 mL/kg during 1 hour before and 1 mL/kg/hr during 6 hours after contrast medium exposure. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the development of contrast-associated acute kidney injury, as defined by the Acute Kidney Injury Network criteria, 72 hours after contrast exposure. Patients randomized to the bicarbonate group (n = 151) showed a higher urinary pH at the end of the infusion than patients randomized to the saline group (n = 156) (6.7 ± 2.1 vs 6.2 ± 1.8, respectively; p < 0.0001). The frequency of contrast-associated acute kidney injury was similar in both groups: 52 patients (33.3%) in the saline group and 53 patients (35.1%) in the bicarbonate group (absolute risk difference, -1.8%; 95% CI [-12.3% to 8.9%]; p = 0.81). The need for renal replacement therapy (five [3.2%] and six [3.9%] patients; p = 0.77), ICU length of stay (24.7 ± 22.9 and 23 ± 23.8 d; p = 0.52), and mortality (25 [16.0%] and 24 [15.9%] patients; p > 0.99) were also similar between the saline and bicarbonate groups, respectively. CONCLUSIONS: Except for urinary pH, none of the outcomes differed between the two groups. Among ICU patients with stable renal function, the benefit of using sodium bicarbonate rather than isotonic sodium chloride for preventing contrast-associated acute kidney injury is marginal, if any.

Pheochromocytoma Crisis in the ICU: A French Multicenter Cohort Study With Emphasis on Rescue Extracorporeal Membrane Oxygenation.

OBJECTIVES: To describe the characteristics, management, and outcome of patients admitted to ICUs for pheochromocytoma crisis. DESIGN: A 16-year multicenter retrospective study. SETTING: Fifteen university and nonuniversity ICUs in France. PATIENTS: Patients admitted in ICU for pheochromocytoma crisis. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We included 34 patients with a median age of 46 years (40-54 yr); 65% were males. At admission, the median Sequential Organ Failure Assessment score was 8 (4-12) and median Simplified Acute Physiology Score II 49.5 (27-70). The left ventricular ejection fraction was consistently decreased with a median value of 30% (15-40%). Mechanical ventilation was required in 23 patients, mainly because of congestive heart failure. Vasoactive drugs were used in 23 patients (68%) and renal replacement therapy in eight patients (24%). Extracorporeal membrane oxygenation was used as a rescue therapy in 14 patients (41%). Pheochromocytoma was diagnosed by CT in 33 of 34 patients. When assayed, urinary metanephrine and catecholamine levels were consistently elevated. Five patients underwent urgent surgery, including two during extracorporeal membrane oxygenation. Overall ICU mortality was 24% (8/34), and overall 90-day mortality was 27% (9/34). Crude 90-day mortality was not significantly different between patients managed with versus without extracorporeal membrane oxygenation (22% vs 30%) (p = 0.7) despite higher severity scores at admission in the extracorporeal membrane oxygenation group. CONCLUSIONS: Mortality is high in pheochromocytoma crisis. Routinely considering this diagnosis and performing abdominal CT in patients with unexplained cardiogenic shock may allow an earlier diagnosis. Extracorporeal membrane oxygenation and adrenalectomy should be considered as a therapeutic in most severe cases.

In Vivo Cysteinyl Leukotriene Release in Allergic and Nonallergic Immediate Hypersensitivity Reactions during Anesthesia.

BACKGROUND: Immediate hypersensitivity reactions occurring during anesthesia are classified as allergic when skin tests and mast cell tryptase are positive and as nonallergic when negative results are obtained. Cysteinyl leukotrienes (cysLTs) are potent mediators synthesized by mast cell and eosinophil that induce bronchial constriction. They could play a role in hypersensitivity reactions. METHODS: cysLT C4, D4, and E4 concentrations were measured by a competition immunoassay in serial plasma samples obtained prospectively from 21 anesthetized controls and retrospectively from 34 patients who reacted at induction of anesthesia (24 with allergic and 10 with nonallergic reactions). RESULTS: In controls, the median (interquartile range) cysLT concentration was 0.83 (0.69 to 1.02) µg/l before anesthesia and was unchanged 30 min, 6 h, and 24 h afterward. In the patients with allergic reactions, the values were highly increased 30 to 60 min after the reaction (17.9 [7.8 to 36.0] µg/l), while the patients with nonallergic reactions had less increased values (7.3 [3.0 to 11.5] µg/l). The difference between the three groups was significant (P < 0.0001). Increased values persisted during the 24 h of observation. Concentrations were significantly higher in patients with bronchospasm (P = 0.016). CONCLUSIONS: cysLTs appear to be an important mediator of allergic and nonallergic immediate hypersensitivity reactions. These findings might open a new field for management of patients with hypersensitivity reactions, especially nonallergic ones.

Rapid Occurrence of Chronic Kidney Disease in Patients Experiencing Reversible Acute Kidney Injury after Cardiac Surgery.

BACKGROUND: There is recent evidence to show that patients suffering from acute kidney injury are at increased risk of developing chronic kidney disease despite the fact that surviving tubular epithelial cells have the capacity to fully regenerate renal tubules and restore renal function within days or weeks. The aim of the study was to investigate the impact of acute kidney injury on de novo chronic kidney disease. METHODS: The authors conducted a retrospective population-based cohort study of patients initially free from chronic kidney disease who were scheduled for elective cardiac surgery with cardiopulmonary bypass and who developed an episode of acute kidney injury from which they recovered. The study was conducted at two French university hospitals between 2005 and 2015. These individuals were matched with patients without acute kidney injury according to a propensity score for developing acute kidney injury. RESULTS: Among the 4,791 patients meeting the authors' inclusion criteria, 1,375 (29%) developed acute kidney injury and 685 fully recovered. Propensity score matching was used to balance the distribution of covariates between acute kidney injury and non- acute kidney injury control patients. Matching was possible for 597 cases. During follow-up, 34 (5.7%) had reached a diagnosis of chronic kidney disease as opposed to 17 (2.8%) in the control population (hazard ratio, 2.3; bootstrapping 95% CI, 1.9 to 2.6). CONCLUSIONS: The authors' data consolidate the recent paradigm shift, reporting acute kidney injury as a strong risk factor for the rapid development of chronic kidney disease.