First nosocomial outbreak of vanA-type vancomycin-resistant Enterococcus raffinosus in France.

BACKGROUND: Vancomycin-resistant Enterococcus raffinosus has rarely been associated with nosocomial infection and outbreaks. AIM: To report the successful control of a nosocomial outbreak of vanA-type vancomycin-resistant E. raffinosus in a surgical intensive care unit. METHODS: The investigation of the outbreak is reported with control measures taken. Molecular typing of vancomycin-resistant E. raffinosus isolates was performed by repetitive sequence-based polymerase chain reaction (PCR). FINDINGS: Between September and October 2014, vancomycin-resistant E. raffinosus isolates were isolated from four patients. The index patient had been hospitalized previously in Portugal, and was not found to be colonized by vancomycin-resistant enterococci on screening cultures obtained at admission. However, vancomycin-resistant E. raffinosus was isolated from a bile sample 19 days after hospital admission. All four isolates were resistant to both vancomycin and teicoplanin due to the presence of the vanA gene, while remaining susceptible to daptomycin and linezolid. Repetitive sequence-based PCR confirmed the spread of a single vanA-positive E. raffinosus clone. Infection control measures including direct PCR screening on rectal specimens, contact precautions, and cohorting of patients and personnel led to successful control of the outbreak. CONCLUSION: This is the first reported outbreak of vanA-type vancomycin-resistant E. raffinosus in France in both clinical and screening specimens among hospitalized patients. The inability of routine selective screening media to detect the vancomycin-resistant E. raffinosus in the index case likely contributed to the outbreak.

Contribution of (1,3)-beta-D-glucan to diagnosis of invasive candidiasis after liver transplantation.

Invasive candidiasis (IC) causes high morbidity and mortality rates after liver transplantation, in part due to delayed diagnosis. The fungal cell wall component (1,3)-beta-d-glucan (BG) could be an early biomarker of IC. This preliminary prospective study was designed to evaluate the contribution of BG measurements to the diagnosis of IC after liver transplantation. All consecutive patients who underwent liver transplantation at Henri Mondor Hospital in France between January and June 2013 were enrolled prospectively in the study. They were monitored weekly for colonization by Candida, and colonization index values were calculated. Serum samples were tested for BG (Fungitell; Cape Cod Inc.) at least weekly between liver transplantation and discharge from the hospital. A total of 52 patients (including 39 male patients) were enrolled, with a median age of 55 years (range, 31 to 69 years). The median Model for End-Stage Liver Disease (MELD) score was 27 (range, 6 to 40). Cultures from 42 patients (81%) yielded Candida spp., with the most common Candida species isolated being Candida glabrata (47%). Six cases of documented IC were found for four of the 52 patients. On the day the clinical diagnosis of IC was made, analysis based on combining two sequential BG-positive samples (>146 pg/ml) and a colonization index of ≥0.5 revealed sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) results of 83%, 89%, 50%, and 97.6%, respectively. The detection of BG associated with Candida colonization may be a promising tool based on a high NPV that can rule out IC among high-risk patients.

Candida vascular complication in a liver transplant recipient due to yeast contamination of preservation solution.

Infections remain a major cause of morbidity and mortality after liver transplantation. One possible cause of infection is preservation fluid contamination. Donor-derived pathogens, such as Candida albicans, have occasionally produced life-threatening complications in organ recipients, already described in renal transplantation. In the present case, we report the loss of a liver graft secondary to vascular complications because of C. albicans found in the preservation fluid. Our case report raises the question of implementing procedures, similar to those in renal transplantation, including early antifungal treatment and repeated radiological monitoring for the prevention and detection of vascular complications.

Outbreak of NDM-1-producing Acinetobacter baumannii in France, January to May 2013.

We report the first outbreak of carbapenem-resistant NDM-1-producing Acinetobacter baumannii in Europe, in a French intensive-care unit in January to May 2013. The index patient was transferred from Algeria and led to the infection/colonisation of five additional patients. Concurrently, another imported case from Algeria was identified. The seven isolates were genetically indistinguishable, belonging to ST85. The bla(NDM-1) carbapenemase gene was part of the chromosomally located composite transposon Tn125. This report underscores the growing concern about the spread of NDM-1-producing A. baumannii in Europe.

[Severe toxic acute liver failure: etiology and treatment]. / Insuffisances hépatiques aiguës sévères d'origine toxique : prise en charge étiologique et symptomatique.

Many substances, drugs or not, can be responsible for acute hepatitis. Nevertheless, toxic etiology, except when that is obvious like in acetaminophen overdose, is a diagnosis of elimination. Major causes, in particular viral etiologies, must be ruled out. Acetaminophen, antibiotics, antiepileptics and antituberculous drugs are the first causes of drug-induced liver injury. Severity assessment of the acute hepatitis is critical. Acute liver failure (ALF) is defined by the factor V, respectively more than 50% for the mild ALF and less than 50% for the severe ALF. Neurological examination must be extensive to the search for encephalopathy signs. According to the French classification, fulminant hepatitis is defined by the presence of an encephalopathy in the two first weeks and subfulminant between the second and 12th week after the advent of the jaundice. During acetaminophen overdose, with or without hepatitis or ALF, intravenous N-acetylcysteine must be administered as soon as possible. In the non-acetaminophen related ALF, N-acetylcysteine improves transplantation-free survival. Referral and assessment in a liver transplantation unit should be discussed as soon as possible.

The effect of fentanyl and remifentanil, with or without ketoprofen, on pain after thyroid surgery: a randomized-controlled trial.

BACKGROUND AND OBJECTIVES: This study was designed to quantify the additional postoperative analgesic efficacy of a single dose of ketoprofen in patients undergoing thyroid surgery using two different intraoperative analgesic regimens. METHODS: One hundred and twenty patients were randomly assigned to one of four groups: intraoperative fentanyl or remifentanil with or without ketoprofen (n = 30 for each group). Intravenous ketoprofen (1.5 mg kg-1) or saline was administered 45 min before the end of surgery. Pain scores, opioid demand and length of stay in the postanaesthesia care unit were assessed in a blinded manner. RESULTS: Patients receiving intraoperative fentanyl with saline had significantly lower visual analogue scale pain scores in the postanaesthesia care unit compared with those receiving intraoperative remifentanil with saline (55 +/- 10 mm vs. 80 +/- 18 mm, P < 0.05) and they stayed shorter in the postanaesthesia care unit (86 +/- 24 min vs. 126 +/- 37 min). In conjunction with intraoperative fentanyl, ketoprofen significantly decreased postoperative pain scores (40 +/- 10 mm, P < 0.05 compared with fentanyl alone) and opioid demand (4 of 30 patients vs. 14 of 30 patients compared with fentanyl alone, P < 0.05). Patients receiving intraoperative remifentanil had no additional analgesic benefit with ketoprofen. CONCLUSION: After thyroid surgery, patients receiving intraoperative fentanyl had lower pain scores and needed less rescue analgesia compared with patients receiving intraoperative remifentanil. The adjunction of ketoprofen further improved analgesia in patients who received intraoperative fentanyl only.

Postoperative pain scores and analgesic requirements after thyroid surgery: comparison of three intraoperative opioid regimens.

PURPOSE: This study was designed to compare the effect on postoperative pain, opioid consumption and the length of stay in postoperative care unit (PACU) after three different intraoperative analgesic regimens in thyroid surgery. METHODS: Seventy five patients were enrolled into the study and assigned to one of three groups, fentanyl, sufentanil or remifentanil (n=25 for each group). Before the end of surgery, paracetamol 1 gr and nefopam 20 mg was also administered in all patients. Pain scores, opioid demand and the length of stay in PACU were assessed in a blind manner. RESULTS: Post operative pain scores were significantly lower in the fentanyl and sufentanil groups compared to remifentanil group (55 +/- 15, and 60 +/- 10 versus 78+/- 12, P < 0.05). Patients in the remifentanil group stayed longer in the PACU 108+/- 37 min versus 78+/-31 and 73 +/- 25 min, (P< 0.05). CONCLUSION: After remifentanil based analgesia, anticipation of postoperative pain with opioid analgesic appears mandatory even for surgery rated as being moderately painful, otherwise longer opioid titration due to higher pain scores might delay discharge time.

[Analgesic effect of continuous intravenous nefopam after urological surgery]. / Effets analgésiques de l'administration intraveineuse continue de néfopam après chirurgie urologique.

OBJECTIVES: To evaluate the efficacy of continuous infusion of nefopam. Indeed this analgesic is commonly used by continuous infusion by many anaesthetists to reduce its adverse effects. However whether the analgesic effect of an intermittent administration of nefopam has been proven, the efficacy of continuous infusion has not been established. STUDY DESIGN: Double-blind placebo controlled prospective randomised study. PATIENTS AND METHODS: Sixty patients ASA 1 to 3 undergoing planned urological surgery with laparotomy were included. At the end of surgery, bolus doses of placebo (Group 3) or nefopam 20 mg (Group 1 and 2) were administered to all the patients. Placebo (Group 3), nefopam 80 mg (Group 1) or 120 mg (Group 2) was thereafter continuously infused over 24 hours. All patients received additional analgesia with PCA morphine. We measured pain at rest and on cough with VAS. Adverse side effects such as nausea and vomiting, sedation and respiratory depression were evaluated. Mental performance was measured with mini mental status tests. RESULTS: Patients were older in the placebo group by approximately six years but anesthetic and surgical variables were not different between groups. Pain at rest and on cough was not statistically different between groups. In the placebo group, the median (interquartile range) morphine consumption reached 29 mg (13-53) whereas in patients receiving 80 and 120 mg nefopam, it levelled to 44 mg (11-54) and 35 mg (9-82) respectively (p > 0.05). Patients needed morphine during the same time period whether they received nefopam or not. Patients suffering from adverse effects were similar between groups. CONCLUSION: In this study, continuous administration of nefopam did not reduce morphine consumption nor ameliorate analgesia and thus may not be recommended in urological surgery. Nefopam pharmacokinetics when used with continuous infusion as well as surgery types and differences in age between groups may explain these results.

[Postoperative nausea and vomiting: cost and therapeutic algorithm. Part II: high-risk patients and late PONV]. / Nausées-vomissements postopératoires (NVPO): avantage et coût d'un algorithme thérapeutique. Partie II: sujets à risque et NVPO tardifs.

OBJECTIVES: To evaluate in high-risk patients and in usual clinical conditions, the efficiency of treatments based on an algorithm on late (24 h) postoperative nausea and vomiting (PONV). STUDY DESIGN: Prospective and descriptive. METHODS: The nature and efficiency of prophylactic and curative PONV treatments was evaluated 24 h after surgery under general anesthesia in patients at high risk of PONV, one and 15 month after the introduction of a clinical and therapeutic algorithm. A risk score based on the type of surgery and patients characteristics determined the prophylactic treatment: high risk = droperidol 1.25 mg + ondansetron 4 mg; moderate risk = droperidol 1.25 mg. Cost of prophylactic and curative treatment was calculated according to the exact number of vials of antiemetics used. RESULTS: The use of the therapeutic algorithm leads to a reduction of PONV by a half (47.7% of 109 patients in 1999 vs. 24.5% of 102 patients in 2001) while twice more patients received a prophylactic treatment (32.1% vs. 75.5%). The number of patients needed to be treated (NNT) according to the algorithm to avoid PONV was 1.8 in this high-risk population. However, the relative risk to have PONV was only reduced by 66% with the combination of two antiemetics in 2001 and 22.5% patients still suffered from PONV despite the double prophylactic treatments. The relative risk of PONV without prophylactic treatment was spontaneously reduced by 25% between the two study periods (54% vs. 40%). After 15 months, the recommendations were followed in 43.1% of patients. A curative treatment was given in the same percentage of patients in 2001 and 1999 (63.4% vs. 68%), but followed the recommendations in fivefold more patients (47% vs. 9.1%). The cost of PONV treatment (prophylactic and curative) was increased by 3.5-fold between the two periods ( 55 for 109 patients vs. 190 for 102 patients). CONCLUSION: The use of a PONV therapeutic algorithm based on a scored risk was associated to a lower reduction of late PONV than already published in the literature while the cost was increased as expected. This suggests the efficacy of antiemetic prophylactic treatment might have been overestimated by large multicenter trials and is less in usual clinical conditions. Thus local evaluation of practice is required by performing quality insurance programs.

[Postoperative nausea and vomiting: cost and advantage induced by a quality insurance programme. Part I: post anaesthesia care unit]. / Nausées-vomissements postopératoires: avantage et coût d'un programme d'assurance qualité. Partie I: en salle de surveillance post-interventionnelle.

OBJECTIVES: To report the efficiency and direct cost induced by a quality insurance programme (QIP) aimed to reduce the incidence of post-operative nausea and vomiting (PONV) in the post-anaesthesia care unit. TYPE OF STUDY: Prospective and descriptive study. METHODS: The occurrence and treatment of PONV were prospectively recorded in the post-anaesthesia care unit in a standardised file before and following therapeutic recommendations made by volunteers component of a QIP. Prophylaxis was administered to patients according to a score of risks based on the type of surgery and patient characteristics. The real cost induced by this change of practice was evaluated according to pharmacists' accounts over 1 year. RESULTS: The QIP was associated to a 33.5% reduction of PONV relative risk and a 50% increase in prophylactic treatments. When this reduction of PONV was extrapolated to the total number of anaesthesia over 1 year, this QIP avoided PONV in 770 patients each year. The increase of cost reached 3572 as the cost by patient receiving a prophylactic treatment increased from 0.66 to 1. CONCLUSION: Despite an increase in the individual cost of PONV prophylaxis, the selection of patients by a "home" score of risk limits the indications of prophylactic treatment. Thus the increase in cost remains in acceptable ranges.

[Hypnosis for treatment of nausea and vomiting: it works!]. / L'hypnose pour traiter les nausées et vomissements: ça marche!

We report a case of uncontrollable vomits in 76-year-old patient, for which hypnosis was effective. Described vomits became initiated by administration of morphine per os, lasted three months and stood up to usual medication as well attempts of nutrition by ballasted micro-tube. Somatic etiology search was unsucceSsful; the growing significance of hypnosis in the field of anesthesia led to use relational and oriented solution therapy. The situation was rapidly and constantly solved.

Remifentanil sedation compared with propofol during regional anaesthesia.

BACKGROUND: The short onset and offset of remifentanil may allow for accurate dosing of sedative effect with few side-effects and rapid recovery. In this study remifentanil is compared with propofol for sedation during successful regional anaesthetic blocks. METHODS: After informed consent was given, 125 patients undergoing surgery under spinal or brachial plexus anaesthesia were randomized to receive, either propofol: bolus 500 microg/kg plus initial infusion 50 microgkg/min or remifentanil: bolus 0.5 microg/kg plus initial infusion 0.1 microgkg/min. Study drug infusion rate was titrated throughout the procedure according to level of sedation and side-effects. Pain, discomfort, sedation level and side-effects were recorded at regular intervals until discharge from the post operative care unit (PACU). RESULTS: Two patients in the remifentanil group versus ten in the propofol group were treated for discomfort or pain during surgery (P<0.02). Due to a significantly higher rate of respiratory depression (46% vs. 19% with propofol, P<0.01) the mean remifentanil infusion rate was decreased to 0.078 +/- 0.028 microgkg/min, whereas it was kept stable with propofol. Propofol patients had significantly higher (P<0.05) sedation levels and experienced more frequent amnesia of the procedure. Eleven propofol patients experienced pain at injection site, versus two remifentanil patients (P<0.02). Nausea and vomiting were more frequent in the remifentanil patients during infusion (27% vs. 2% in the propofol group, P<0.001) but similar postoperatively. Time to discharge from PACU was similar in the two groups. CONCLUSION: Propofol results in less respiratory depression and nausea when sedation is needed during a case with a successful regional block. Remifentanil may be considered as an alternative if pain during the procedure is a major concern or if amnesia is contraindicated.

[Surgery of the internal carotid: locoregional or general anesthesia?]. / Chirurgie de la carotide interne: anesthésie locorégionale ou générale?

AIM OF THE STUDY: The aim of this retrospective study was to assess the advantages of regional anesthesia over general anesthesia in carotid artery surgery. PATIENTS AND METHOD: From January 1989 to December 1998, 670 patients with severe internal carotid artery stenosis were operated in the same center and were classified into two groups according to the type of anesthesia: group I, general anesthesia (n = 312) and group II, regional anesthesia (n = 358). Characteristics of the two groups were almost similar except for a higher rate of unstable heart disease in group I and bypass grafts in group II. RESULTS: A shunt was used in 16.3% of cases in group I and in 8.4% in group II. Complications resulting from the use of a shunt and intraoperative complications observed with regional anesthesia were reported. There was a conversion from regional to general anesthesia in 6 patients. Median duration of clamping was longer in group II (30 min vs 25 min). Cardiac complication rates were similar in the two groups, particularly cardiac mortality (0.6%). There were more pulmonary and miscellaneous complications in group I. Neurological complications were more frequent in group I, particularly fatal strokes (1% versus 0%). Neurological mortality and morbidity cumulative rates were 3.1% and 1.5%, respectively, not significantly different. CONCLUSION: These results, in agreement with those of the literature, confirm that carotid artery endarterectomy is associated with a low rate of neurological mortality and morbidity. Although regional anesthesia was associated with a lower rate of complications, we are not allowed to conclude to its superiority, as the present study was retrospective and the difference was not statistically significant.

A Kantian argument for a duty to donate one's own organs. A reply to Nicole Gerrand.

Nicole Gerrand is right to criticize Munzer for not connecting a person's dignity to the "capacity to exhibit humanity by acting rationally." However, connecting these does not mean that they are one and the same concept. Gerrand fails to make two distinctions that are decisive in the context of Kant's ethics. First, she does not distinguish between vital organs, integral organs and mere "accumulations", each of which requires a specific moral argument. Second, she does not distinguish between human rational nature in itself, or the capacity to have free will, and the possibility of action rationally, or freedom of choice. Having drawn these distinctions, I argue that Kant's own principles fully allow certain kinds of organ transplants such as blood, skin and marrow transplants from living bodies as well as the transplantation of both vital organs and essential organs from fresh corpses. In fact, Kant's own moral principles should make of these an enforceable duty of right. Unlike Gerrand, then, I think that the question of whether or not donors should be paid--and the patient should pay--is a key issue even in a Kantian context.

A comparison of two techniques for cervical plexus blockade: evaluation of efficacy and systemic toxicity.

UNLABELLED: We compared two techniques of cervical plexus blockade (CPB) for carotid endarterectomy. Cervical plexus nerve block was performed with a combination of bupivacaine and lidocaine, with injections at the C2-C3, C3-C4, and C4-C5 transverse processes in 11 patients (classical CPB) or with a single injection after localization of the cervical plexus with a nerve stimulator in 12 patients (interscalene CPB). Pain scores were obtained during block placement and at predetermined phases of the operation. Arterial blood was sampled before and 3, 5, 8, 10, 15, 25, 40, and 60 min after CPB for measurement of bupivacaine and lidocaine concentrations. Interscalene CPB was less painful than classical CPB. The techniques appeared equally effective. Patients in both groups required equivalent supplementation with IV fentanyl and additional local infiltration with lidocaine during the most painful stages of surgery. The maximal concentration of bupivacaine was lower in interscalene CPB compared with classical CPB (1.0 microg/mL versus 1.5 microg/mL, P < 0.01). The time required to reach the maximal concentration of bupivacaine was 15 (10-40) min in interscalene CPB and 10 (5-17) min in classical CPB (P < 0.05). Lidocaine maximal concentration was similar in both groups, however the time required to reach the maximal concentration was longer (P < 0.05) in interscalene CPB (15 [10-60] min) than in classical CPB (10 [8-20] min). We conclude that the interscalene CPB is as effective as the classical CPB as a regional technique for carotid endarterectomy and may be associated with a lower systemic absorption of bupivacaine. IMPLICATIONS: Cervical plexus blockade for carotid endarterectomy can be effectively performed with a single injection after localization of the cervical plexus with a nerve stimulator. This technique is simple and was associated with less systemic absorption of local anesthetic than the multiple-injection technique.

Comparison of the effects of mivacurium on the diaphragm and geniohyoid muscles.

Although subjects often report difficulty with swallowing shortly after receiving neuromuscular blocking agents, difficulty with swallowing during recovery from neuromuscular blocking agents appears to be infrequent. We have used electromyography to compare onset and recovery at the diaphragm and geniohyoid airway muscles after an intubating dose of mivacurium (0.2 mg kg-1) to determine if the geniohyoid muscles were particularly sensitive to neuromuscular blocking agents. Twelve adults undergoing elective surgery were anaesthetized with propofol and fentanyl and the trachea intubated without neuromuscular blocking agents. The left hypoglossal and right phrenic nerves were stimulated with percutaneous needle electrodes and the electromyogram recorded with surface electrodes. EMG responses were measured after a bolus dose of mivacurium 0.2 mg kg-1. Recordings were also made of the mechanical response of the adductor pollicis to supramaximal ulnar nerve stimulation. There was no difference in the rate of onset of block for geniohyoid muscles and the diaphragm, but recovery to 25% and 90% of the control response was shorter at the diaphragm (median 14.5 (95% confidence limits 12.9-15.3) min and 23.8 (21.7-26) min) than at the geniohyoid muscle (19.4 (15.6-20.1) min and 29.2 (26.3-31.4) min), respectively (P < 0.05). When the train-of-four ratio of the mechanical response of the thumb reached 70%, the diaphragm and geniohyoid muscles had recovered completely in all patients.

Comparison of duration of neuromuscular blocking effect of atracurium and vecuronium in young and elderly patients.

In a controlled, randomized study, we evaluated duration of neuromuscular block in 80 patients undergoing routine abdominal surgery. Forty patients were aged 18-50 yr (control group) and 40 patients were more than 65 yr (elderly group). All patients had normal plasma creatinine concentrations. After induction of anaesthesia, patients were allocated randomly to receive either atracurium 0.5 mg kg-1 or vecuronium 0.1 mg kg-1 to facilitate tracheal intubation. Monitoring of the evoked response of the adductor pollicis muscle to supramaximal single twitch ulnar nerve stimulation every 10 s was performed and measured with a strain gauge. Repeat doses of atracurium 0.1 mg kg-1 or vecuronium 0.02 mg kg-1 were administered when the adductor pollicis response recovered to 25% of the control twitch height. We found that the duration of action of the initial dose of atracurium was similar in the control and elderly groups, and it did not vary after repeated doses. However, the initial dose of vecuronium caused a significantly longer period of clinical block in the elderly group compared with the controls, and the duration of action of repeated doses was longer in the elderly group. We conclude that as there is a risk of prolonged effect of vecuronium in the elderly, monitoring of neuromuscular function is recommended in this group. Alternatively, atracurium should be preferred for prolonged surgery in elderly patients.

Onset of neuromuscular block is the same if the ipsilateral or contralateral limb to the injection site is used for monitoring.

We studied 40 healthy adult patients undergoing elective surgery who were premedicated with flunitrazepam. Before induction of anaesthesia, one of the upper limbs was cannulated and an i.v. infusion of 0.9% saline commenced. Patients were given fentanyl and thiopentone for induction of anaesthesia and then 50% (20 patients) received atracurium 0.5 mg kg-1 and the other 50% vecuronium 0.1 mg kg-1. Neuromuscular block (maximum degree of depression of the elicited first twitch and the onset time of depression of twitch height to 50%, 90% and 100% of control) and skin temperature (at the thenar eminence) were monitored in both the limb with the i.v. infusion and the non-cannulated upper limb. There was no difference in onset time and degree of neuromuscular block between the two upper limbs. Skin temperature was not significantly different between the two upper limbs. We conclude that each upper limb, irrespective of whether an i.v. infusion is in progress, may be used for monitoring onset of neuromuscular block.