[Epidemiology of cerebral perioperative vascular accidents]. / Épidémiologie des accidents vasculaires cérébraux périopératoires.

OBJECTIVES: Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature. ARTICLE TYPE: Systematic review. DATA SOURCES: Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters. RESULTS: In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients. CONCLUSION: Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.

White coats: how long should doctors wear them?

OBJECTIVES: While coat contamination increases progressively with the duration of use, there are no guidelines on how frequently medical white coats should be changed. The purpose of our study was to examine the turnover of individual batch of medical white coats in a university hospital. STUDY DESIGN AND METHODS: A retrospective analysis of the white coat turnover of 826 physicians was performed by using the hospital laundry computerized database and an electronic declarative survey (240 responses) to evaluate the duration of medical white coat use. RESULTS: There was a wide discrepancy between the data extracted from the laundry database and those from the survey. The median factual duration of use (20 days, range: 15-30) corresponding to a turnover of 2 (1-2) coats per month, was widely underestimated by the physicians. Multivariate analysis identified 4 independent factors associated with a declared use of coats longer than 7 days: estimation of insufficient gown turnover (OR 14.8 [4.8-45.8]), daily change considered as not useful (OR 5.1 [2.4-10.8]), non-medical specialty (OR 2.95 [1.5-5.6]) and presence of stains on gowns (2.9 [1.5-5.5]). CONCLUSION: Shortening white coat use should be included in medical education in order to improve the good practice rules of hospital hygiene.

[Use of a single-use fiberscope for the training in tracheal intubation under fiberscopy on labyrinth]. / Utilisation d'un fibroscope à usage unique pour la formation sur labyrinthe à l'intubation sous fibroscope.

GOAL OF THE STUDY: To evaluate a single-use fiberscope, the Ascope-Trainer, for the training in the intubation under fiberscope. TYPE OF STUDY: Prospective randomized study approved by the local ethic committee. METHODOLOGY: After evaluation of their level of expertise, "experienced" or "novices" in intubation under fiberscope, the doctors attending the Training for Referents in Difficult Airway Management performed a test on labyrinth with a standard fiberscope (T1). After they were assigned to two groups, training with the Ascope-Trainer (group A, n=35) or with a classic fiberscope (group C, n=29), they trained during 15 minutes and performed a new test (T2). An analysis of variance was used to compare means. A goal for the training was determined according to the "experienced" doctors' mean T1. A test of Khi(2) was used for the comparison of the number of participants having reached this goal as well as the progress in both groups A and C. RESULTS: The T1 in the "experienced" group was 76 ± 31 s and the training improved significantly T2 (53 ± 17 s). Considering the novices, T2 was significantly lower than T1 in the group A (77 ± 38 s versus 135 ± 68 s) as well as in C (64 ± 28 s versus 122 ± 60 s), and the proportion of the novices having reached the goal of training was comparable in both groups. CONCLUSIONS: Because its use is similar to the standard fiberscope, the Ascope-Trainer may be interesting for this type of training.

Operative care and surveillance in severe trauma patients. Interference between resuscitation treatments and anaesthesiology, and consequence on immunity.

Major trauma remains a worldwide cause of morbi-mortality. Early mortality is the consequence of hemorrhagic shock and traumatic brain injury. During early resuscitation, anaesthesia is often mandatory to perform surgery. It is mandatory to master the hemodynamic effects of hypnotic drugs in order to anticipate their potential deleterious effects in the setting of hemorrhagic shock. After early resuscitation, trauma patients present a high prevalence of nosocomial pneumonia, which sustains major morbidity. Nosocomial pneumonia are the consequence of an overwhelming systemic inflammatory response syndrome (SIRS) as well as a trauma-related immunosuppression. The administration of hemisuccinate of hydrocortisone modulates the SIRS and reduces the risk of nosocomial pneumonia as well as the length of mechanical ventilation. Finally in the operating theatre, fighting against hypothermia and un-anatomical positions, which can aggravate rhabdomyolysis, are both mandatory.

Ammonia plasma concentration and prolonged infusion of remifentanil in patients with acute kidney injury.

BACKGROUND: Glycine is an excipient of remifentanil and may induce side effects. To investigate glycine and ammonia concentration with the use of remifentanil in Intensive Care Unit patients with acute kidney injury (AKI) defined by a decrease in creatinine clearance above 50%. METHODS: Prospective open-label cohort study in three surgical Intensive Care Units. Thirty-three patients with AKI and requiring sedation for at least 72 hours. Sedation with remifentanil and midazolam or propofol was adapted every six hours according to ATICE. Glycine and ammonia plasma concentrations were measured at H0 (start of infusion) and every 12 hours during a continuous intravenous 72 hours remifentanil infusion, and 24 hours after the end of the infusion. Clinical and biological glycine or ammonia toxicity were evaluated. RESULTS: Fifteen patients required continuous veno-venous hemodiafiltration (CVVHDF). Glycine and ammonia plasma concentrations exceeded the normal value respectively for 11 (33%) and 15 (45%) patients before remifentanil infusion (H0). Accumulation of glycine or ammonia was observed neither for patients with or without CVVHDF. For patients without CVVHDF, the plasma ammonia concentration at the end of remifentanil infusion was significantly correlated with the creatinine clearance at H72 (P=0.03) and with the mean rate of remifentanil infusion (P=0.002). No side effect was reported. CONCLUSION: Remifentanil was not associated with an accumulation of glycine or ammonia in patients with AKI. Plasma ammonia concentration was correlated with the mean rate of remifentanil and creatinine clearance. A 72-hours remifentanil infusion appeared safe for sedation of patients with AKI.

[Perioperative aspects of blood transfusion in paediatrics]. / Aspects périopératoires de la transfusion sanguine en pédiatrie.

In pediatric elective surgery, the main indications of blood transfusion are cardiac surgery, neurosurgery and abdominal tumors. Blood saving techniques are also available. The transfusion threshold has to take into account the physiological age-related particularities. Underestimation of blood loss and delayed transfusion are associated with a severe morbidity. In the absence of specific literature, the management of hemorrhagic shock is based on extrapolation of the adult recommendations.

[New training tools in haemovigilance]. / Nouveaux outils de formation en hémovigilance.

The transfusion of blood and blood products is a complex, multi-professional task which is liable to errors from donor to recipient. Simulation is a new training tool in medicine which may result with an improvement for safety and quality of care without any risk for the patient. Different simulators are available: haptic system and low fidelity mannequin for technical skills, software, full scale intermediate to high fidelity mannequin, actors and virtual reality. For haemovigilance training, actors and intermediate to high fidelity mannequins could be used to simulate complex professional situations with identity mistake and crisis management. The environment of full scale simulation is expensive and need technical and pedagogic skills.

[Brain injury, immunity and infections]. / Agressions cérébrales, immunité et infections.

Infections are a major cause of death and morbidity after acute injury of the central nervous system (CNS). Acute lesions of the CNS alter immune homeostasis contributing to the development of immunosuppression (IS), and making the bed of the infection. IS results in a decreased phagocytic functions of neutrophils and macrophages as well as monocyte deactivation (decreased capacity of antigen presentation to lymphocytes). The immune abnormalities occur very quickly and may last for weeks. The neurovegetative system is closely connected to the secondary lymphoid organs where cells of innate immunity receive information from injured organs inducing the long lasting adaptive immune response (immune synapse). The sympathetic system is critically involved in the IS through production of anti-inflammatory mediators like interleukin-10. This may prove important as all types of acute injury of the CNS can lead to direct damage to sympathetic centers. Specialized units of care for ischemic stroke, taking into account the risk of infection related to the IS, have improved the prognosis until 18th month after the initial damage of the SNC. It is now well recognized that the improved long-term prognosis is related with the secondary prevention of recurrent ischaemia as well as aggressive management of pulmonary infections. A better understanding of the pathophysiology of IS can be considered in the near future, opening the door to immunomodulatory therapeutic trials.

Risk factors of postoperative vomiting in children receiving continuous intravenous morphine.

BACKGROUND: Risk factors of postoperative vomiting (POV) have been less extensively explored in children compared to adults. We analyzed the risk factors of POV in children receiving continuous intravenous (i.v.) morphine in a standardized manner without POV prophylaxis after major surgery. METHODS: This observational retrospective study included 235 children aged from 2 to 216 months (91 F:144 M, 11.5% <6 months, 31.5% 6-11 months). The primary end point was the occurrence of at least one episode of POV recorded on the nursing chart. The independent predictors of POV were determined by univariate analysis followed by a multivariate analysis by logistic regression. The data are presented as either medians (25th-75th percentile) or as values with a 95% confidence interval. RESULTS: Continuous i.v. morphine was administered over 42 (22-60) h with an initial infusion rate of 20 µg x kg(-1) x h(-1) in 63% of cases, which was increased in 31.5% of cases and was accompanied by an additional bolus in 39.2% of children. At least one episode of POV occurred in 22.6% of children. The following three independent factors were associated with POV: female gender (OR 3.324 [1.695-6.519], P=0.0005), urological surgery (OR 5.605 [1.291-24.340], P=0.0214) and age (OR 1.012 [1.006-1.018], P<0.0001). The discriminating characteristics of the model were good with an ROC curve AUC of 0.778, sensitivity of 71.7% and specificity of 71.4% for a 0.22 cut-off value of POV incidence. The positive predictive value was 42.2%, and the negative predictive value was 89.6%. CONCLUSION: Female gender, which is usually considered a risk factor after puberty, should be taken into account independent of age to guide the POV prophylaxis in children receiving a postoperative continuous i.v. morphine infusion.

[Opinion of different professional categories about the intensity of procedural pain in adult intensive care units]. / Estimation de la douleur induite par les soins de réanimation par les différentes catégories de soignants.

OBJECTIVES: to assess the procedures considered as the most painful by health personnel of two adult critical care units. METHODS: individual written survey with a questionnaire about 46 potentially painful procedures. Each individual has to estimate the pain intensity as well as the frequency of performance for each painful procedures. RESULTS: one hundred questionnaires were provided (15 physicians, 71 nurses and 14 auxiliaries). The rate of answer was 53 % and 2110 scores were recorded and analyzed. The insertion of a pleural drain was associated with the higher pain score (7.5 [6.5-9]). Discrepancies were observed between the professional categories in ranking painful procedures. However, the mobilization of a severe trauma patient, the removal of an otorhinolaryngological or a pleural drain were classified in the 10 most painful procedures by physicians, nurses as well as auxiliaries. Whatever the procedure was, the median global scores estimated by the auxiliaries (n=385; 6 [4-7]) were higher than those corresponding to the nurses (n=1267; 5 [3-7]) (p<0.01). Nurses attributed a higher score than the physicians for 39 of 46 procedures. No relation was found between the estimated pain intensity and the estimated frequency of the procedures. CONCLUSION: as in paediatrics, adult intensivist physicians underestimate pain during procedure comparing with nurses and auxiliaries. Consequently, health care professionals should elaborate protocols to accurately assess, prevent, or treat painful procedures in intensive care units.

Propofol versus sevoflurane for fiberoptic intubation under spontaneous breathing anesthesia in patients difficult to intubate.

BACKGROUND: The most recommended technique for the management of patients with a difficult airway is fiberoptic intubation (FOI). The aim of this study was to compare propofol and sevoflurane for FOI performance in patients who were difficult to intubate. METHODS: Seventy-eight patients scheduled for maxillo-facial surgery were included in this prospective, randomized study. The airway was topically anesthetized with lidocaine 5% before performance of FOI with propofol TCI (group P) or sevoflurane (group S). The following parameters were recorded: rate of success, duration of the induction and of the FOI, BIS and PETCO2 values. A visual analogic scale (VAS) was used to monitor the technical difficulties as well as the recall of patients and their satisfaction. The respiratory and hemodynamic complications were also evaluated. RESULTS: Induction and procedure duration were significantly shorter in group S compared with group P. The rate of successful FOI was not different: 38 cases (97%) in group P and 35 cases (90%) in group S. No significant differences were observed between groups regarding BIS values and VAS values for technical difficulties and for patient recall and satisfaction. The incidence of hypertension or tachycardia was significantly higher in group S compared with group P. The incidence of respiratory complications was not significantly different between the groups, but three patients experienced obstructive dyspnea with hypoxemia. CONCLUSION: Propofol and sevoflurane provide a high success rate for the performance of FOI in patients who are difficult to intubate.

[Withholding or withdrawing of life sustaining therapies in emergency context. Perception by anaesthesiologists]. / Limitation ou arrêt de thérapeutiques actives en situations d'urgence. Le point de vue des anesthésistes réanimateurs.

OBJECTIVES: One objective is to state more accurately the difficulties met by the anaesthesiologists in an emergency context in case of withholding or withdrawing life sustaining therapies. STUDY DESIGN AND PARTICIPANTS: A questionnaire addressed to anaesthesiologists of nine hospitals in the extreme West part of France. MATERIALS AND METHODS: The questionnaires were sent and returned by mail in order to guarantee confidentiality. RESULTS: The participation rate was 40% with 172 questionnaires analysed. Ninety-eight per cent of the anaesthesiologists have already participated in a withholding or withdrawing life sustaining treatments, and in an emergency context in 92% of the cases. In that last case, criteria related to the severity of the clinic presentation and to the short-term death probability influence the decision made to interrupt life-sustaining therapies. For 93% of anaesthesiologists, the decision should be collegial, but 50% of them had already made such a decision alone. The withdrawal of ventilatory support was the most difficult decision to make. Withdrawing mechanical ventilation or extubating appeared impossible for 23.4 and 50% of the anaesthesiologists respectively. Providing comfort care to the patients with end of life decision was essential for 100% of the anaesthesiologists, but 11% of them used and considered analgesic and sedation after withholding or withdrawing life sustaining treatments as euthanasia. The complaint possibility worried 57% of the anaesthesiologists and influenced the writing of the process or giving information to the families respectively for 65 and 75%. The righting of the medical files could be improved for 92% of the anaesthesiologists. CONCLUSION: The decision of withholding and withdrawing life sustaining treatments in an emergency context is based on the conviction of short-term death probability. Withholding and withdrawing life sustaining treatments is a decision made according to the principles of collegiality and necessary comfort cares, but the procedure can still be improved, especially in the redaction of the medical file and the ethical and juridical control of these extreme situations.