Compliance with evidence-based clinical management guidelines in bleeding trauma patients.

BACKGROUND: In 2007, the multidisciplinary European Task Force for Advanced Bleeding Care in Trauma published guidelines for the management of the bleeding trauma patient. The present study aimed to assess compliance with the European guidelines during the first 24 h in a level I trauma centre and to determine whether compliance impacts mortality. METHODS: This was a retrospective study of consecutive bleeding trauma patients referred to a university hospital in France between 2010 and 2014. A reference document was developed on the basis of the European guidelines to transform the guidelines pragmatically into 22 objectively measurable criteria. We measured per-patient and per-criterion compliance rates and assessed the impact of guideline compliance on mortality. RESULTS: A total of 121 bleeding trauma patients were included. The median (interquartile range) per-patient compliance rate was 75 (65-82)% and the per-criterion compliance rate 64 (57-81)%. Mortality rates were 18 and 32% at 24 h and 30 days, respectively. After adjusting for injury severity, per-patient compliance rates were associated with decreased mortality at 24 h (odds ratio per 10% increase in patient compliance score, 0.43; 95% confidence interval 0.26-0.71; P = 0.0001) and at 30 days (odds ratio per 10% increase in patient compliance score, 0.47; 95% confidence interval 0.31-0.72; P = 0.0004). CONCLUSIONS: We found that compliance with protocols based on European guidelines impacts trauma outcome, because patient compliance was associated with survival. Further work is needed to improve adherence to these guidelines, with ongoing monitoring to ensure best practice and optimal patient outcome.

Inflammation affects sufentanil consumption in ulcerative colitis.

BACKGROUND: Previous studies have demonstrated an increased perioperative opioid requirement during inflammatory disease. To evaluate the influence of the inflammatory process, we studied in the same patient the sufentanil requirement during procedures that occur during two distinct phases of ulcerative colitis with different inflammatory profiles: (1) left colectomy for major colitis unresponsive to medical treatment during acute inflammation and (2) coloprotectomy with ileoanal anastomosis, three months after recovery of the acute inflammatory episode. METHODS: Sixteen patients with clinical and histological evidence of ulcerative colitis scheduled for colectomy with ileoanal anastomosis were included. For each surgical procedure, anaesthesia was induced with sufentanil 0.5 microg kg(-1) and propofol 2 mg kg(-1). Patients were ventilated with 50% nitrous oxide and oxygen, and tidal volume was adjusted to keep end-tidal CO2 at 30 mmHg. Anaesthesia was maintained with end-tidal isoflurane at 0.5%. Analgesia was achieved with continuous infusion of sufentanil at 0.3 microg kg(-1) h(-1). Additional boluses of sufentanil and increases in infusion rates were used when haemodynamic variables increased to more than 20% of preoperative values. Sufentanil consumption during surgery was analysed by Wilcoxon signed rank sum test. P < 0.05 was considered significant. RESULTS: Total intra-operative sufentanil requirement was significantly larger during colectomy performed for acute inflammatory colitis than during ileoanal anastomosis performed after the inflammatory process (1.24 +/- 0.48 microg kg(-1) h(-1) vs. 0.62 +/- 0.3 microg kg(-1) h(-1); P < 0.05). CONCLUSION: For the same patient, inflammatory status influences opioid requirements during surgery for ulcerative colitis.

Inflammation increases sufentanil requirements during surgery for inflammatory bowel diseases.

BACKGROUND AND OBJECTIVE: Inflammation promotes hyperalgesia and increases opioid binding protein (alpha1-acid glycoprotein) inducing increased opioid requirement. To investigate the influence of an acute episode of inflammatory bowel disease in opioid requirement during major abdominal surgery, 17 patients with Crohn's disease, 12 patients with ulcerative colitis and seven patients without any inflammatory process (control group) were prospectively studied. Sufentanil requirements were assessed during surgery. METHODS: Sufentanil administration was adjusted when haemodynamic variables changed more than 20% of preoperative values. In a subgroup of 20 patients (Crohn's disease: 7, ulcerative colitis: 7, control group: 6), plasma concentrations of alpha1-acid glycoprotein and unbound sufentanil were measured. Total plasma clearance of sufentanil was also determined. Data presented as median (25-75 per thousand) were analysed by non-parametric and ANOVA tests. RESULTS: Despite similar surgery duration, intraoperative sufentanil requirements were significantly larger in both the Crohn's disease group (0.9 (0.6-1.6) microg kg(-1) h(-1)) and the ulcerative colitis group (1.1 (0.6-1.7) microg kg(-1) h(-1)) than in the control group (0.5 (0.4-0.5) microg kg(-1) h(-1)). Total plasma clearance of sufentanil was larger in patients with inflammatory bowel disease than in the control group. The plasma alpha1-acid glycoprotein concentration was increased in the inflammatory bowel disease group. However, the free fraction of sufentanil was similar in all three groups. The largest sufentanil consumption in patients with inflammatory bowel disease was observed during time of pain stimulation in the area of referred hyperalgesia from the affected viscus. In the control group, the sufentanil requirement was constant throughout surgery. CONCLUSION: Inflammatory bowel disease increases opioid requirement during major abdominal surgery.

Randomized controlled trial of a synthetic sealant for preventing alveolar air leaks after lobectomy.

BACKGROUND: The intraoperative application of synthetic surgical lung sealant (SLS) to surfaces leaking air or at risk of air leaks has been advocated to reduce alveolar air leaks (AAL) after lobectomy. METHODS: This study was designed to investigate the effectiveness of SLS in reducing AAL in patients considered intraoperatively to have moderate to severe AAL, after all conventional measures to reduce such leaks had been used. Over 17 months, 124 patients undergoing standard lobectomy were randomized to standard closure of parenchymal surgical sites, with or without SLS. RESULTS: In treated patients, the mean numbers of intraoperative AAL after application of SLS were significantly smaller than in untreated patients (38.5 mL versus 59.9 mL, p = 0.0401). Postoperatively, the mean time to last observable AAL was shorter in the treated group (33.7 hours versus 63.2 hours, p = 0.0134) and the mean percentage of patients free of AAL at days 3 and 4 was smaller (87% versus 58.5%, p = 0.002). However, the occurrence of incomplete lung expansion after drain removal, and the length of the postoperative hospital stay due to prolonged AAL, were not different. In the treatment group, 4 patients developed localized empyema and incomplete lung expansion without bronchopleural fistula 7, 12, 15, and 20 days, respectively, after operation. In these 4 patients, inserted chest tubes drained infected sealant. CONCLUSIONS: Surgical lung sealant may be a useful adjunct to conventional techniques for reducing moderate and severe AAL after lobectomy, but its use seems to increase the risk of postoperative empyema.

Superior vena cava syndrome of malignant origin. Which surgical procedure for which diagnosis?

OBJECTIVE: Since some malignancies causing superior vena cava syndrome (SVCS) are only sensitive to a specific treatment regimen, it is crucial to diagnose the underlying pathology in such cases. The aim of the present study was to review the surgical procedures used to establish the aetiology of SVCS of a malignant origin. METHODS: This retrospective study was based on a series of 88 patients referred to surgeons for SVCS, for whom biological and/or endoscopic procedures had failed to establish the diagnosis. On the basis of the results of clinical examination, biological tests and CT-scan presentation, we performed 99 sampling procedures to obtain a diagnosis for all 88 patients. These procedures were the following: biopsy of peripheral adenopathy (n=11), CT-guided biopsy (CTGB; n=23), axial mediastinoscopy (MDS; n=23), anterior mediastinotomy (n=26), anterior mediastinoscopy (n=6), biopsy of the suprascapular mass (n=3), pericardioscopy (n=3), thoracoscopy (n=1), thoracotomy (n=2) and sternotomy (n=1). RESULTS: Per-operative morbidity consisted of one case of massive venous bleeding during MDS requiring a salvage sternotomy to achieve hemostasis. The diagnoses finally established for the 88 patients were non-Hodgkin's lymphoma (NHL) for 36, small cell lung cancer for 25, non-small cell lung cancer for 17, Hodgkin's disease for five, thymoma for three, germ cell tumour for one and sarcoma for one. For the diagnosis of lung cancer, the sensitivities of CTGB and MDS were 85 and 100%, respectively. For the diagnosis of NHL, the sensitivity of anterior mediastinotomy was 95%. CONCLUSION: The surgical diagnostic procedure, chosen on the basis of the clinical presentation and CT-scan, can be performed safely in the case of SVCS, with the same accuracy as in the absence of this syndrome. Among the patients referred to surgeons, NHL is the most frequent aetiology of SVCS, together with small cell lung cancer.