Management of antiplatelet therapy for non elective invasive procedures of bleeding complications: proposals from the French working group on perioperative haemostasis (GIHP), in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR).

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society of Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals on the management of antiplatelet therapy for non-elective invasive procedures or bleeding complications. The proposals were discussed and validated by a vote; all proposals could be assigned with a high strength. Emergency management of oral antiplatelet agents (APA) requires knowledge on their pharmacokinetic/pharmacodynamics parameters, evaluation of the degree of the alteration of haemostatic competence and the associated bleeding risk. Platelet function testing may be considered. When APA-induced bleeding risk may worsen the prognosis, measures should be taken to neutralise antiplatelet therapy by considering not only the efficacy of available means (which can be limited for prasugrel and even more for ticagrelor) but also the risks that these means expose the patient to. The measures include platelet transfusion at the appropriate dose and haemostatic agents (tranexamic acid; rFVIIa for ticagrelor). When possible, postponing non-elective invasive procedures at least for a few hours until the elimination of the active compound (which could compromise the effect of transfused platelets) or if possible a few days (reduction of the effect of APA) should be considered.

Enhanced recovery after elective colorectal resection outside a strict fast-track protocol. A single centre experience.

INTRODUCTION: Optimising the management of hospitalised patients is a major concern. In colorectal surgery, the concept of enhanced recovery has been popularised by means of "fast-track" protocols, aiming at patient's discharge on the second postoperative day. Nevertheless, a strict fast-track protocol has several limitations. It is very demanding for the patient and therefore applicable only to a limited number of patients. AIM: In order to optimise, in every aspect, the postoperative recovery of each patient undergoing an elective colorectal resection inside our institution, we set up a "soft" enhanced recovery programme. MATERIAL-METHODS: A retrospective analysis was conducted in 92 patients evaluating the respective impact of protocol application throughout the duration of the hospital stay. RESULTS: When all the required measures of our protocol were correctly implemented, the median discharge day was postoperative day 3 (range 3-5 days). On the contrary, when deviations occurred, they resulted in longer hospital stay (p < 0.001). Patients operated by laparoscopy were discharged earlier than patients operated by laparotomy (p < 0.001). The use of nasogastric tube and postoperative drainage prolonged significantly the length of stay (p = 0.001 and p < 0.001 respectively). When the urinary catheter was not removed or oral feeding not resumed on postoperative day 1, the patients were discharged later (p < 0.001). CONCLUSIONS: There are substantial possibilities of optimising the recovery process after an elective colorectal resection, outside a strict fast-track protocol.

[Rivaroxaban: Xarelto--recommendations for pharmacists]. / Le Rivaroxaban (Xarelto): guide de la pratique officinale.

Rivaroxaban is one of the new oral anticoagulants (NOACs). It has many potential advantages in comparison with Vitamin K Antagonists (VKA). It has a predictable anticoagulant effect and does not theoretically require biological monitoring. It is also characterized by less food and drug interactions. However, due to major risks associated with over- and under-dosage, its optimal use in patients should be carefully followed by health care professionals. The aim of this article is to provide recommendations for pharmacists on the practical use of Xarelto in its different approved indications. This document is adapted from the practical user guide of rivaroxaban which was developed by an independent group of Belgian experts in the field of thrombosis and haemostasis.

Ketamine has no effect on bispectral index during stable propofol-remifentanil anaesthesia.

BACKGROUND: Ketamine 0.15-1 mg kg(-1) decreases postoperative morphine consumption, but 0.5 mg kg(-1) is associated with an increase in the bispectral index (BIS) values that can lead to an overdose of hypnotic agents. The purpose of our investigation was to study the effect of ketamine 0.2 mg kg(-1) administered over a 5 min period on the BIS during stable target-controlled infusion (TCI) propofol-remifentanil general anaesthesia. METHODS: Thirty ASA I or II patients undergoing abdominal laparoscopic surgery were included in this double-blind, randomized study. Anaesthesia was induced and maintained with a TCI of propofol and remifentanil. After 5 min of steady-state anaesthesia (BIS at 40) without surgical stimulation, patients received either an infusion of ketamine 0.2 mg kg(-1) or normal saline. The test drug was infused over 5 min. Standard parameters and BIS values were recorded every minute until 15 min post-infusion. RESULTS: The baseline mean (sd) value for the BIS was 37 (6.5) for the ketamine group and 39 (8.2) for the placebo group. The highest mean BIS value during the recording period was 41.5 (8.7) for the ketamine group and 40.1 (8.9) for the placebo group. BIS values were not statistically different between the groups (P=0.62); there was no significant change over time (P=0.65) with no group-time interaction (P=0.55). CONCLUSIONS: Under stable propofol and remifentanil TCI anaesthesia, a slow bolus infusion of ketamine 0.2 mg kg(-1) administered over a 5 min period did not increase the BIS value over the next 15 min.

New anticoagulant drugs: monitoring and perioperative strategies.

Arterial and venous thromboses are major causes of mortality and morbidity. In Western countries, more than 1% of the population takes an antithrombotic agent. Many of these patients will need to undergo surgery and decisions need to be made regarding whether to continue their antithrombotic medication and risk increased bleeding or to stop it and potentially increase the risk of thrombosis. Anaesthesiologists, therefore, need to be aware of the basic pharmacology of the available agents as well as their individual indications, contraindications, and adverse effects. In this review we will discuss these aspects, and also discuss new antithrombotic agents that are currently being developed to improve efficacy and to increase safety in comparison with conventional agents. New coagulation monitoring devices will also be discussed.

Value of the MELD score for the assessment of pre- and post-liver transplantation survival.

The MELD score has now been implemented in the United States for liver allocation, but it has not been validated in Europe. Its association with posttransplant outcome is unclear. Optimal cutoff values of MELD and Child-Pugh scores to predict death on the liver waiting list were defined in a series of 137 cirrhotic patients listed for liver transplantation. Six-month actuarial survival while on the waiting list was 90% with a Child-Pugh <11 and MELD <17, whereas it decreased progressively to 40% at 6 months after listing for those having a Child-Pugh and MELD score >10 and >16. Analysis of a series of 112 patients (85 chronic liver disease and 27 hepatocellular carcinoma) revealed no change in MELD value at the time of transplantation compared to the score at the time of listing (mean +/- SD: 15.5 +/- 7.7 vs 15 +/- 5.8) with a mean waiting time of 118 days. Using either the optimal cutoff for MELD score (<17 or >16) or seven different strata (3 to 7, 8 to 10, 11 to 13, 14 to 16, 17 to 19, 20 to 22, 23 to 39), whether measured at listing or just before liver transplantation, there was no significant difference (chi(2) 4.97, P = .58) in survival: 82.7% and 63% at 6 and 60 months, overall. Our data confirm that the MELD score with only three parameters is as good as the Child-Pugh score to predict mortality on the Eurotransplant waiting list. The optimal cutoff to assess higher priority for the bad category is >16. There was no negative impact on short- or long-term prognosis of the bad categories of MELD.

Local ablative treatments for liver metastases: the current situation.

Surgical resection is the optimal treatment for liver metastases. However, due to their multifocality and/or insufficient remnant liver volume, the majority of liver metastases are unresectable. For this reason, several local ablative techniques have been developed, aiming to produce selective tumour destruction and thus increase the rate of patients amenable to curative-intent treatments. Among these techniques, cryoablation and radiofrequency ablation only have proven to have a curative potential, while transarterial chemoembolization and alcohol injection should be considered as palliative options only. The local recurrences after cryoablation and radiofrequency are equivalent, inferior to 10%, highly dependent of selection criteria. In contrast, morbidity is significantly increased after cryoablation, leading most of the teams to prefer the radiofrequency approach. Two major limitations for radiofrequency are, first, the risk to provoke heat biliary lesion in case of metastases located proximally to hilar plate, and second, the risk of insufficient ablation due to a cooling effect in case of metastases near to major vessels. Keeping in mind these limitations, selective use of radiofrequency may offer a significant benefit by allowing complete tumour clearance in patients with unresectable liver metastases.

Plasma substitution effects of a new hydroxyethyl starch HES 130/0.4 compared with HES 200/0.5 during and after extended acute normovolaemic haemodilution.

BACKGROUND: The volume expansion effect of a recently introduced hydroxyethyl starch, HES 130/0.4, was compared with the commonly used HES 200/0.5 after rapid infusion of a single large dose (up to 2 litres) administered during acute normovolaemic haemodilution (ANH). METHODS: This prospective, randomized, double-blind study included 40 patients scheduled for major abdominal surgery with no contraindication to ANH. Patients were randomized to undergo ANH with either HES 130/0.4 (n=20) or HES 200/0.5 (n=20). Blood was collected to reach a target haemoglobin level of about 8.0 g dl(-1) and simultaneously replaced by the same volume of colloid (HES 130: 1825 [SD 245] ml; HES 200: 1925 [183] ml). Heart rate, mean arterial pressure, cardiac filling pressure, and cardiac output were measured before induction of anaesthesia (baseline), 10 min after completion of ANH, before surgery, at the end of surgery and on the following morning (postoperative day 1; POD1). ANH blood was systematically retransfused during surgery or before POD1. RESULTS: Exchange of about 40% of blood volume resulted in similar haemodynamic changes in both groups. Filling pressures increased significantly, while cardiac index remained unchanged (HES 130: from 3.3 [0.4] to 3.2 [0.7] litre min(-1) m(-2); HES 200: from 3.0 [0.6] to 3.1 [0.7] litre min(-1) m(-2)). Need for crystalloids and colloids was similar between the groups during surgery and on POD1. Total blood loss (HES 130: median 2165 ml, range 660-2970 ml; HES 200: median 2464 ml, range 640-19 380 ml) and amount of allogeneic red blood cells transfused (HES 130: median 0, range 0-4 units; HES 200: median 0, range 0-18 units) were comparable in the two groups. CONCLUSIONS: This study demonstrates a good immediate and medium-term plasma volume substitution effect of HES 130 compared with HES 200. HES 130 could represent a suitable synthetic colloid for plasma volume substitution during extensive ANH.

Does the platelet function analyser (PFA-100) predict blood loss after cardiopulmonary bypass?

BACKGROUND: This study was designed to determine if a new point-of-care test (PFA-100) platelet function analyser) that assesses platelet function predicts blood loss after cardiac surgery. METHODS: and results. Blood samples from 70 patients were drawn before and after cardiopulmonary bypass (CPB) for PFA-100 measurements. The system consists of a cartridge in which a membrane and an aperture are coated with either collagen/adenosine-5'-diphosphate or collagen/epinephrine. The instrument determines the time required for full occlusion of the aperture (closure time). We observed a weak correlation between pre-CPB collagen/epinephrine closure time and second-hour mediastinal blood loss (r=0.34, P=0.01). The sensitivity and positive predictive value of the PFA-100 measurements were comparable to platelet count for predicting excessive bleeding after CPB (75 and 27% vs 100 and 25%, respectively). CONCLUSIONS: The PFA-100 is a logical test for detecting patients who could have excessive bleeding after CPB. However, the PFA-100 was not able to separate patients at low risk of subsequent bleeding from those who had substantial bleeding.

[Multidisciplinary approach of hepatic metastasis of colorectal origin]. / Approche multidisciplinaire des métastases hépatiques d'origine colorectale.

Surgery remains the only potentially curative treatment for liver metastases. After margin free resection, approximately 30% of the patients present long-term survival. Due to the metastases number and/or volume, only 10 to 15% of the patients are candidates for curative-intent surgery. Thus, the objectives of the diagnostic and therapeutic management are to select adequately the patients for surgery and to improve resection rate by the use of neoadjuvants methods. Positron emission tomography could improve the preoperative detection of hepatic and extrahepatic metastases leading to the exclusion of some patients from useless surgical exploration. For patients with initially resectable tumors, no benefit has been demonstrated for adjuvant chemotherapy. For non resectable metastases, two neoadjuvants methods should be evaluated, chemotherapy to reduce tumor volume and portal vein embolization of the tumor side to improve the hepatic functional reserve and allow larger resection. For non-accessible lesion, selective tumor destruction using radiofrequency offers promising perspectives. In conclusion, the multiplication of the diagnostic and therapeutic methods certainly improve the global management of patients with liver metastases but also makes more difficult the individual choice for the best treatment. For this reason, a multimodal approach is absolutely mandatory.

[The anesthesiology-recovery department]. / Le Service d'Anesthésiologie Réanimation.

The Department of Anesthesiology and Reanimation is organised in units with clinical activities, which include the pre-operative care of patients, anesthesiological care and immediate post-operative supervision. Two post-operative treatment rooms also form part of the department. The main fields of research of the various units result from collaborations with other departments of Hôpital Erasme, in particular with regard to the development of advanced techniques or fit within the confines of the speciality.

Domino hepatic transplantation using the liver from a patient with primary hyperoxaluria.

BACKGROUND: We report a case of domino liver transplantation using the liver harvested from a patient who underwent a combined liver and kidney transplantation for primary hyperoxaluria (PH). METHOD: A cadaveric liver transplantation was performed in a 19-year-old man with PH. In a second step, the PH liver harvested from the first patient was transplanted in a 69-year-old man with hepatitis C-related cirrhosis, not a candidate for a classic liver graft owing to multifocal hepatocellular carcinoma. RESULTS: At 8 months after transplantation, the domino recipient has normal hepatic function and no signs of tumoral recurrence, but he progressively developed hyperoxalemia, hyperoxaluria, and renal insufficiency. CONCLUSION: Regarding the favorable postoperative clinical evolution, domino liver transplantations using livers from PH patients may represent a new opportunity for marginal candidates for liver transplantation. However, the progressive renal insufficiency expected in such domino recipients should limit this procedure to selected cases.

Haemostatic disorders during liver transplantation.

Profound and complex coagulation disorders are encountered during liver transplantation. They include preoperative coagulation disorders related to the liver disease and haemostatic changes related to the procedure itself. They commonly lead to increased intraoperative bleeding, especially due to increased fibrinolysis, the contribution of which can be demonstrated by the relative efficacy of antifibrinolytics. Given the multifactorial nature of bleeding in liver transplantation, preoperative coagulation tests cannot predict blood loss even if some statistical relationship is occasionally found. Preoperative correction of coagulation defects has not been shown to be effective in reducing intraoperative bleeding. Throughout the procedure, a rapid and sensitive method for monitoring coagulation is necessary in order to guide the rational use of blood components and pharmacological agents. The usefulness of such a method to assist management of blood loss or blood component requirements is poorly documented and controversial.