[Preoperative cardiac-risk assessment for non-cardiac surgery: The French RICARDO survey]. / Évaluation du Risque CARDiaque de l'Opéré (RICARDO) : enquête nationale auprès des anesthésistes-réanimateurs concernant la prise en charge périopératoire du patient à risque cardiaque.

OBJECTIVES: Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations. MATERIALS AND METHODS: Since June to September 2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations. RESULTS: We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography. CONCLUSION: This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one.

Pediatric tonsillectomy: clinical practice guidelines.

OBJECTIVE: This article presents the Clinical Practice Guidelines for Pediatric Tonsillectomy of the French Society of ENT and Head and Neck Surgery (SFORL), entitled "Amygdalectomie de l'enfant : Recommandation pour la pratique clinique" (SFORL, 2009). METHOD: The French Society of ENT (SFORL), in partnership with the French Association for Ambulatory Surgery (AFCA) and French Society for Anaesthesia and Intensive Care (SFAR), set up a representative panel in the fields of anesthesiology, ENT and head-and-neck surgery, pediatrics, sleep medicine and general medicine. Following the literature analysis reported in the Presentation of the Guidelines, recommendations were drawn up taking account of risk/benefit ratios, levels of evidence, feasibility in pediatric tonsillectomy and baseline risk assessment in the relevant population. RESULTS: Around 50,000 pediatric tonsillectomies, with or without associated adenoidectomy, are performed in France each year. Postoperative morbidity and mortality are non-negligible, despite progress in peri-operative management. The present guidelines address the following questions: 1) What are the indications for tonsillectomy, notably in case of obstructive sleep disorder; 2) What pre-operative assessment is required? 3) What are the technical principles involved? 4) What are the selection criteria for ambulatory tonsillectomy? 5) How should postoperative follow-up be organized? 6) How should complications be managed? CONCLUSION: The present Clinical Practice Guidelines for pediatric tonsillectomy in France should improve clinical and organizational practices to enhance patient safety. They seek to ensure optimal conditions of care for all children undergoing tonsillectomy.

Reducing the risk of anaphylaxis during anesthesia: 2011 updated guidelines for clinical practice.

These guidelines represent the updated consensus of experts in the field of immediate hypersensitivity reactions occurring during anesthesia. They provide a series of valid, widely accepted, effective, and easily teachable guidelines that are the fruit of current knowledge, research, and experience. The guidelines are based on the findings of international scientific research and have been implemented in France under the auspices of the French Society for Anaesthesia and Intensive Care (Société Française d'Anesthésie et de Réanimation [SFAR]) and the French Society of Allergology (Société Française d'Allergologie [SFA]). The members of the European Network for Drug Allergy approved the guidelines. This paper presents the most relevant clinical implications of the guidelines.

Desynchronization of daily rest-activity rhythm in the days following light propofol anesthesia for colonoscopy.

Anesthesia and surgery are associated with fatigue and sleep disorders, suggestive of disturbance of the circadian rest-activity rhythm. Previous studies on circadian rhythm disturbance were focused on patients undergoing general anesthesia associated with surgery. This does not permit one to draw valid conclusions about the effects of general anesthesia per se on circadian rhythms. Our study was set up to determine the impact of a hypnotic dose of propofol on the circadian rest-activity rhythm in humans under real-life conditions. Seventeen healthy subjects scheduled to receive light propofol anesthesia for ambulatory colonoscopy were investigated. Their rest-activity rhythms were assessed using actigraphic monitoring. Diurnal rest was increased, whereas nocturnal sleep was unchanged in the days following anesthesia. Nonparametric analyses showed a decrease in the strength of coupling of the rhythm to stable environmental zeitgebers and increase of fragmentation of the rhythm after anesthesia. Light general anesthesia itself impairs synchronization of the circadian rest-activity rhythm to local time in patients by acting directly on the circadian clock.

[Ambulatory surgery: safety, quality]. / Chirurgie ambulatoire: sécurité, qualité.

Demands related to regulation of Ambulatory surgery in France and to expectations of the patients implies that we can be able to proof that ambulatory organization guarantees total patient care with optimal safety conditions; and that detection of unexpected events is the first step in a larger approach to continue quality improvement and minimize risks for patients. To achieve these goals, we suggest a list of means based on international ambulatory surgery definitions, including clinical indicators, frequent asked questions and measurement of patient satisfaction.

[Ambulatory surgery: safety, quality]. / Chirurgie ambulatoire: sécurité, qualité.

Demands related to regulation of ambulatory surgery in France and to expectations of the patients imply that we can be able to proof that ambulatory organization guarantees total patient care with optimal safety conditions and that detection of unexpected events is the first step in a larger approach to continue quality improvement and minimize risks for patients. To achieve these goals, we suggest a list of means based on international ambulatory surgery definitions, including clinical indicators, frequent asked questions and measurement of patient satisfaction.

[Anesthesia in elderly patients: results of an INSERM survey]. / Le sujet âgé anesthésié: résultats de l'enquête INSERM.

This study analyses the results of a national prospective inquiry, made in France between 1978 and 1982, with regard to patients over 60-year-old. In this group, including 20% of all surgical patients, occur 54% of all complications and 65% of all cardiac arrests related to anaesthesia (partially or totally). The complications are mainly circulatory and less often respiratory. Among the latter the major events are unrecognized ventilatory depression and aspiration of gastric content during recovery period. These data substantiate the necessity of an adequately staffed and equipped recovery room.

[Rapid sequence muscular relaxation: vecuronium versus succinylcholine]. / Curarisation à séquence rapide: vécuronium versus succinylcholine.

Onset times and conditions of endotracheal intubation were compared in 340 patients. They were all classified ASA I or II and free from any condition which might interfere with the pharmacokinetics or pharmacodynamics of muscle relaxants. The patients were randomly assigned to 4 groups where different muscle relaxation techniques with vecuronium were used: "priming" group (n = 150, 10 micrograms.kg-1 followed by 100 micrograms.kg-1 4 min later), "high dose" group (n = 70, 250 micrograms.kg-1), "control" group (n = 60, 100 micrograms.kg-1) and "succinylcholine" group (n = 60, 1 mg.kg-1). All anaesthetic conditions were otherwise similar. Electromyographic monitoring of the hypothenar muscles displayed no impairment in the reaction to a train-of-four stimulus during the pre-relaxation period (4 min) in the "priming" group. No incident was observed in these patients. Ten % of control response were obtained in 61, 86, 135 and 210 s respectively, whereas maximum muscle blockade was obtained in 97, 174, 314 and 74 s respectively. Intubation scoring showed that optimum conditions were obtained when muscle responses were almost fully abolished. These data are in disagreement with those reports on the priming technique where intubation is carried out 60 s after administration of the relaxing dose.

["Pagetoid reticulosis" (Woringer and Kolopp disease). A disease of the Merkel cell (author's transl)]. / La "réticulose pagétoïde" de Woringer et Kolopp. Une maladie de la cellule de Merkel.

A case of Woringer and Kolopp disease "Pagetoid reticulosis" is described. Clinical features include a ring of a target pattern of erythemato-squamous infiltrated skin lesion. The characteristic histological aspect of dense epidermal infiltrate by abnormal cells with a spared dermis has been observed. Ultrastructural findings include cytoplasmic granules with a found electron dense core and close relationship to neurites, two features of the Merkel cell of human normal epidermis. By comparing our patients with the already reported cases of Woringer and Kolopp disease it seems likely that this is a unique disease with no relationship with cutaneous lymphoma but which is defined by a Merkel cell proliferation.