Alveolar recruitment manoeuvre results in improved pulmonary function in obese patients undergoing bariatric surgery: a randomised trial.

Perioperative ventilation is an important challenge of anaesthesia, especially in obese patients: body mass index is correlated with reduction of the pulmonary volume and they develop significantly more perioperative atelectasis and pulmonary complications. The alveolar recruitment manoeuvre is the most effective technique to reverse atelectasis. However, the clinical benefit on lung function in the perioperative period is not clear. The aim of the present study is to assess the perioperative clinical results of systematic alveolar recruitment manoeuvre associated with protective ventilation in patients undergoing laparoscopic bariatric surgery. It was a single-centre, randomised, double blind, superiority trial: control group with standard protective ventilation and recruitment group with protective ventilation and systematic recruitment manoeuvre. The primary outcome was a composite clinical criterion of pulmonary dysfunction including oxygen saturation, oxygen needs and dyspnoea in recovery room and at day 1. Secondary outcomes were recruitment manoeuvre tolerance, pulmonary and non-pulmonary complications, length of hospital stay and proportion of Intensive Care Unit admission. Two hundred and thirty patients were included: 115 in the recruitment manoeuvre group and 115 in the control group, 2 patients were excluded from the analysis in the control group. Patients in the recruitment manoeuvre group had significantly lower rate of pulmonary dysfunction in the recovery room (73% versus 84% (p = 0.043) and 77% versus 88% at postoperative day 1 (p = 0.043)). No significant differences were found for secondary outcomes. No patient was excluded from the recruitment manoeuvre group for intolerance to the manoeuvre. Recruitment manoeuvre is safe and effective in reducing early pulmonary dysfunction in obese patients undergoing bariatric surgery.

Sciatic nerve block or not for outpatient total knee arthroplasty? Study protocol for a randomized controlled trial.

BACKGROUND: The number of patients operated on for total knee arthroplasty (TKA) is growing worldwide. Outpatient surgery is defined by a length of stay (LOS) in the hospital of less than 12 h. This can be limited for TKA, with the efficient management of pain and perioperative complications, such as blood loss, affecting a safe hospital discharge. Outpatient TKA with a suitable protocol, including multimodal measures, could improve the success rate of this procedure. Among the main measures, single-shot sciatic nerve block in association with continuous femoral nerve block for pain control needs to be evaluated in outpatient TKA. Furthermore, to promote the safety of the postoperative period and to accelerate rehabilitation, patients who undergo ambulatory TKA could be discharged to a rehabilitation center on the day of surgery to screen adverse events and to optimize the rehabilitation process. This study is designed to assess the benefits of sciatic nerve block in postoperative pain relief for outpatient TKA. METHODS/DESIGN: This randomized prospective controlled study will be conducted in the knee unit of the teaching hospital of the Nice university and will include 40 patients undergoing primary unilateral outpatient TKA, discharged the day of surgery to a private rehabilitation center for enhanced recovery after surgery, after a hospital stay of less than 12 h. Before surgery, all patients will receive a continuous femoral nerve block with 2 mg/ml ropivacaine 20 ml, and then patients will be randomly assigned to receive or not receive a single-shot sciatic nerve block with 2 mg/ml ropivacaine, 20 ml. The primary outcome measure is the success rate of outpatient TKA. This rate is defined by patients discharged from the hospital to a rehabilitation center the day of surgery with no re-hospitalization due to insufficient pain control before the fifth postoperative day. Secondary outcomes include the incidence of major and minor adverse events during the first five postoperative days and measurement of the quality of recovery using the Knee injury and Osteoarthritis Outcome Score and the new International Knee Society scores plus the Quality of Recovery-40 questionnaire. DISCUSSION: The assessment of anesthesia and rehabilitation protocols enabling major orthopedic surgery, such as TKA, is necessary. This randomized controlled study will address the hypothesis that a suitable multimodal protocol including sciatic nerve block could improve pain control and thus improve the success rate of outpatient TKA. TRIAL REGISTRATION: EudraCT, 2016-000226-19. Registered on 15 April 2016.

Non-invasive Evaluation of NAFLD with Indocyanine Green Clearance Test: a Preliminary Study in Morbidly Obese Patients Undergoing Bariatric Surgery.

BACKGROUND: Overweight and obesity dramatically increased in the last years. Hepatic complication of obesity, integrated in the term of non-alcoholic fatty liver disease (NAFLD), is a spectrum of abnormality ranging from steatosis to non-alcoholic steatohepatitis (NASH), potentially leading to cirrhosis. Liver biopsy remains the gold standard to evaluate the stage of NAFLD; however, the procedure is invasive. The indocyanine green (ICG) clearance test is performed since years to assess hepatic function before partial hepatectomy, or after liver transplantation. This study was designed to detect liver complications with the ICG clearance test in a population of obese patients scheduled for bariatric surgery. METHODS: In a prospective cohort study, morbidly obese individuals receiving bariatric surgery with scheduled hepatic biopsies were investigated. Liver function was determined by the ICG test preoperatively, and blood samples were collected. Liver biopsy specimens were obtained for each patient and classified according to the NAFLD activity score (NAS) by a single pathologist that was blinded to the results of the ICG test. RESULTS: Twenty-six patients were included (7 male and 19 female). The mean age of participants was 45.8 years; the mean body mass index was 41.4 kg/m2. According to the NAS, 6 (23.1%) patients revealed manifest NASH, and 5 patients were considered borderline (19.2%). A closed correlation was observed between the ICG clearance test and hepatic steatosis (r = 0.43, p = 0.03), NAS (r = 0.44, p = 0.025), and fibrosis (r = 0.49, p = 0.01). CONCLUSIONS: In obese patients, non-invasive evaluation of liver function with the indocyanine green clearance test correlated with histological features of NAFLD. This may detect non-invasively hepatopathy in obese population and could motive biopsy.

[Perioperative management of diabetic patient]. / Prise en charge anesthésique du patient diabétique.

The prevalence of diabetes is rising and diabetics may soon represent more than 5% of the world population. The type 2 diabetes is a major independent risk factor for coronary artery disease. The screening for silent myocardial ischemia (IMS) must be systematic. The autonomic dysfunction and the cardiac microcirculatory disorders are at risk of hypotension and hypothermia during anesthesia. After 10 years of diabetes duration the incidence of perioperative complications and of difficult intubation are increased. The neurological deficits related to anesthesia are associated with general anesthesia in 85% of cases. Particular care will be provided during the surgical procedure to avoid skin, muscular and neurologic cuts. In most cases, the regional anesthesia will be preferred to general anesthesia. To avoid hypoglycemia, blood glucose concentration less than 11 mmol.L(-1)(2g.L(-1)) seems a reasonable target during and after surgery.

[Impact of a hospice home visit team on unwanted hospitalization of terminally-ill patients at home in acute medical emergencies]. / Impact d'une équipe d'urgence spécialisée sur les hospitalisations non désirées de patients en phase terminale à domicile.

OBJECTIVES: This study was undertaken to evaluate the impact of paramedical hospice specialists on hospitalization of terminally-ill patients in acute medical emergencies. METHOD: In this intervention, the SAMU (French medical emergency call center) responded to requests for emergency aid at the homes of terminally-ill patients by sending to the patient's home, together with a physician and the emergency ambulance team, a team composed of a nurse and a volunteer, both trained in hospice (terminal) care . When the patient wished to stay at home, the hospice team remained to support the patient and family and to provide comfort care until the crisis situation stabilized. This before-and-after study compares SAMU calls during the first year of the intervention to those in the preceding year. RESULTS: During the intervention period, 14% of patients were hospitalized compared with 48% during the reference year (p<0.0001), for a relative risk of hospitalization of 0.29. The emergency hospice team was considered to be not only complementary but also essential in emergency medical situations for patients receiving palliative care at home. Interaction with existing services did not present problems. Families benefited from considerable assistance in particularly difficult situations. CONCLUSION: A team of paramedical hospice specialists, acting on request of the SAMU, provides a concrete and useful response to problems of unwanted hospitalization in acute emergencies for home-based terminally ill patients. This type of organization is consistent with respect for the patient's choice to remain at home until the end of life. Prevention of unwanted hospitalization and heroic measures should undoubtedly result in cost savings more than sufficient to fund this program.

Effects of intrathecal midazolam on postoperative analgesia when added to a bupivacaine-clonidine mixture.

BACKGROUND: Previous clinical and experimental studies have shown that a midazolam-clonidine mixture has a synergistic antinociceptive effect. This study evaluated the postoperative analgesic effect of adding midazolam to an intrathecal bupivacaine-clonidine mixture. METHODS: One hundred ten patients scheduled to undergo elective lower-extremity surgery were enrolled in this double-blind, randomized trial. Spinal anesthesia was administered by using 1 of 2 mixtures. Group B-C received 12.5 mg isobaric 0.5% bupivacaine, 30 mug clonidine, and 0.4 mL 0.9% saline. Group B-C-M received the B-C mixture plus 2 mg of midazolam in a 0.4-mL solution. Motor and sensory block levels were assessed before, during, and after the procedure until regression of the block to S2. Sedation levels were determined before anesthesia, during surgery, and at the end of the procedure. Postoperative analgesia was assessed every 15 minutes by using a visual analog scale. Duration of sensory and motor blocks was determined based on a modified Bromage scale, and time of the first pain relief request was noted. RESULTS: Duration of sensory block, time of first postoperative analgesic request, and amount of postoperative morphine administered were comparable between groups. However, the motor blockade lasted significantly longer in the B-C-M group compared with the B-C group (287 +/- 73 minutes vs 257 +/- 72 minutes, respectively; P < .05). CONCLUSION: Addition of midazolam to an intrathecal B-C mixture does not potentiate postoperative analgesia but prolongs the motor blockade.

Performance of target-controlled sufentanil infusion in obese patients.

BACKGROUND: Because obesity might affect pharmacokinetic parameters, the authors evaluated the accuracy of target-controlled sufentanil infusion in morbidly obese patients using a pharmacokinetic model usually applied to a normal-weight population. METHODS: Target-controlled propofol and sufentanil coinfusions were administered to 11 morbidly obese patients (body mass index: 45.0 +/- 6.5 kg/m2 ) undergoing laparoscopic gastroplasty. The target plasma propofol concentration was 3 micro g/ml. The effect-site sufentanil target concentration was initially 0.4 ng/ml but was modified during surgery as a function of blood pressure and heart rate. Plasma sufentanil concentrations were measured from the onset of infusion until 24 h after its termination. The predicted sufentanil target concentrations were calculated by STANPUMP software. Intrasubject data analyzed included calculation of performance error, median performance error, median absolute performance error, divergence, and wobble. Pharmacokinetic analysis was performed using a nonlinear mixed effect model. RESULTS: Applied sufentanil target concentrations ranged from 0.3 to 0.65 ng/ml. The mean +/- SD plasma sufentanil concentration measured during spontaneous ventilation was 0.13 +/- 0.03 ng/ml. Median performance error (range) was -13% (-42 to 36%). Median absolute performance error was 26% (8-44%) during infusion and 17% (12-59%) for the 24 h after its completion. The pharmacokinetic sets used slightly overpredicted the concentrations, with a median divergence of -3.4% (-10.2 to 3.1%) during infusion. For body mass index greater than 40, the overestimation of plasma sufentanil concentrations was greater. A two-compartment model with proportional error for interindividual variability best fitted the data. The residual variability was modeled as an additive (0.016 ng/ml) or proportional error (23%). Clearance, central volume of distribution, intercompartmental clearance, and peripheral volume of distribution (coefficient of variation) were 1.27 l/min (23%), 37.1 l (20%), 0.87 l/min (44%), and 92.7 l (22%), respectively. CONCLUSION: The pharmacokinetic parameter set derived from a normal-weight population accurately predicted plasma sufentanil concentrations in morbidly obese patients.

[Emergencies in patients undergoing palliative care at home. A qualitative study of telephone calls to Center 15]. / Urgences chez les patients en soins palliatifs à domicile. Une étude qualitative des appels vers un Centre 15.

INTRODUCTION: The Samu-Centres 15 (French medical emergency centers) are regularly solicited for patients undergoing palliative treatment at their homes and presenting acute complications. No specific response is foreseen for such situations. However, the problems are frequent and crucial. Who is the most appropriate person to intervene? Should the patient be hospitalised or not? Does the patient require reanimation? What are the patients' and families' needs in such circumstances? In an attempt to outline the answers, we collected the opinion of the families concerned. METHOD: We interviewed all the families soliciting the Samu for emergencies concerning patients undergoing palliative treatment at home. To collect their feelings and experience, we used a survey in the form of non directive interviews. RESULTS: In a month, 12 telephone calls concerning our matter were received by the Centre 15 of the Alpes-Maritimes. The interview with the families revealed many elements such as loneliness, guilty feelings, responsibility, surprise when the death occurs, the poor adaptation of the structures and the lack of training of the emergency medical staff. CONCLUSION: The issues underlined require enhanced attention: how can we help the families in such situations? How should the emergency medical staff be trained in accompanying death and palliative treatment? Are the existing structures adapted?

The treatment of severe pulmonary edema induced by beta adrenergic agonist tocolytic therapy with continuous positive airway pressure delivered by face mask.

IMPLICATIONS: We report the case of a pregnant patient who developed severe pulmonary edema secondary to beta-adrenergic agonist tocolytic therapy (salbutamol) and was successfully treated with mask-delivered continuous positive airway pressure ventilation.