Diaphragm thickness modifications and associated factors during VA-ECMO for a cardiogenic shock: a cohort study.

BACKGROUND: The incidence, causes and impact of diaphragm thickness evolution in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock are unknown. Our study investigates its evolution during the first week of VA-ECMO and its relationship with sweep gas flow settings. METHODS: We conducted a prospective monocentric observational study in a 12-bed ICU in France, enrolling patients on the day of the VA-ECMO implantation. The diaphragm thickness and the diaphragm thickening fraction (as index of contractile activity, dTF; dTF < 20% defined a low contractile activity) were daily measured for one week using ultrasound. Factors associated with diaphragm thickness evolution (categorized as increased, stable, or atrophic based on > 10% modification from baseline to the last measurement), early extubation role (< day4), and patients outcome at 60 days were investigated. Changes in diaphragm thickness, the primary endpoint, was analysed using a mixed-effect linear model (MLM). RESULTS: Of the 29 included patients, seven (23%) presented diaphragm atrophy, 18 remained stable (60%) and 4 exhibited an increase (17%). None of the 13 early-extubated patients experienced diaphragm atrophy, while 7 (46%) presented a decrease when extubated later (p-value = 0.008). Diaphragm thickness changes were not associated with the dTF (p-value = 0.13) but with sweep gas flow (Beta = - 3; Confidence Interval at 95% (CI) [- 4.8; - 1.2]. p-value = 0.001) and pH (Beta = - 2; CI [- 2.9; - 1]. p-value < 0.001) in MLM. The dTF remained low (< 20%) in 20 patients (69%) at the study's end and was associated with sweep gas flow evolution in MLM (Beta = - 2.8; 95% CI [- 5.2; - 0.5], p-value = 0.017). Odds ratio of death at 60 days in case of diaphragm atrophy by day 7 was 8.50 ([1.4-74], p = 0.029). CONCLUSION: In our study, diaphragm thickness evolution was frequent and not associated with the diaphragm thickening fraction. Diaphragm was preserved from atrophy in case of early extubation with ongoing VA-ECMO assistance. Metabolic disorders resulting from organ failures and sweep gas flow were linked with diaphragm thickness evolution. Preserved diaphragm thickness in VA-ECMO survivors emphasizes the importance of diaphragm-protective strategies, including meticulous sweep gas flow titration.

Is a care pathway for enhanced recovery after colorectal surgery environmentally responsible?

INTRODUCTION: Above and beyond the environmentally responsible operating theater, the environmental impact of the pathways of surgically treated patients seems essential but has seldom been considered in the literature. On a parallel track, enhanced recovery programmes (ERP) programs are presently deemed a standard of care. The objective of this review is to determine the carbon footprint of the ERP approach in colorectal surgery. METHOD: This a narrative review based on articles referenced in PubMed. Our search was centered on the environmental impact of an ERP in the context of colorectal surgery. A number of measures included in the national and international guidelines were studied. We utilized the terms "carbon footprint", "sustainability", "energy cost", "environmental footprint", "life cycle assessment" AND a key word for each subject found in the ERP recommendations. RESULTS: Most ERP measures in the context of colorectal surgery are factually or intuitively virtuous from an ecological standpoint. With a 3-day reduction in average hospital stay resulting from ERP, the program permits a reduction of at least 375kg CO2e/patient (Appendices 1 and 2). The most substantial part of this reduction is achieved during the perioperative period. While some measures, such as short fasting, are ecologically neutral, others (treatment of comorbidities, smoking cessation, hypothermia prevention, antibiotic prophylaxis, laparoscopy, absence of drains or probes, thromboprophylaxis, early feeding and mobilization…) lead to fewer postoperative complications, and can consequently be considered as environmentally responsible. Conversely, other measures, one example being robotic surgery, leave a substantial carbon footprint. CONCLUSION: ERP is congruent with two pillars of sustainable development: the social pillar (improved patient recovery, and better caregiver working conditions fostered by team spirit), and the economic pillar (decreased healthcare expenses). While the third, environmental pillar is intuitively present, the low number of published studies remains a limitation to be overcome in future qualitative studies.

A randomized controlled trial of the intraoperative use of noninvasive ventilation versus supplemental oxygen by face mask for procedural sedation in an electrophysiology laboratory.

PURPOSE: The efficacy of noninvasive ventilation (NIV) during procedures that require sedation and analgesia has not been established. We evaluated whether NIV reduces the incidence of respiratory events. METHODS: In this randomized controlled trial, we included 195 patients with an American Society of Anesthesiologists Physical Status of III or IV during electrophysiology laboratory procedures. We compared NIV with face mask oxygen therapy for patients under sedation. The primary outcome was the incidence of respiratory events determined by a computer-driven blinded analysis and defined by hypoxemia (peripheral oxygen saturation < 90%) or apnea/hypopnea (absence of breathing for 20 sec on capnography). Secondary outcomes included hemodynamic variables, sedation, patient safety (composite scores of major or minor adverse events), and adverse outcomes at day 7. RESULTS: A respiratory event occurred in 89/98 (95%) patients in the NIV group and in 69/97 (73%) patients with face masks (risk ratio [RR], 1.29; 95% confidence interval [CI], 1.13 to 1.47; P < 0.001). Hypoxemia occurred in 40 (42%) patients in the NIV group and in 33 (34%) patients with face masks (RR, 1.21; 95% CI, 0.84 to 1.74; P = 0.30). Apnea/hypopnea occurred in 83 patients (92%) in the NIV group vs 65 patients (70%) with face masks (RR, 1.32; 95% CI, 1.14 to 1.53; P < 0.001). Hemodynamic variables, sedation, major or minor safety events, and patient outcomes were not different between the groups. CONCLUSIONS: Respiratory events were more frequent among patients receiving NIV without any safety or outcome impairment. These results do not support the routine use of NIV intraoperatively. STUDY REGISTRATION: ClinicalTrials.gov (NCT02779998); registered 4 November 2015.

RéSUMé: OBJECTIF: L'efficacité de la ventilation non invasive (VNI) pendant les interventions nécessitant une sédation et une analgésie n'a pas été établie. Nous avons évalué si la VNI réduisait l'incidence des complications respiratoires. MéTHODE: Dans cette étude randomisée contrôlée, nous avons inclus 195 patient·es de statut physique III ou IV selon l'American Society of Anesthesiologists pendant des interventions en laboratoire d'électrophysiologie. Nous avons comparé la VNI à l'oxygénothérapie par masque facial pour les patient·es sous sédation. Le critère d'évaluation principal était l'incidence des complications respiratoires déterminée par une analyse en aveugle assistée par ordinateur et définie par une hypoxémie (saturation périphérique en oxygène < 90 %) ou une apnée/hypopnée (absence de respiration pendant 20 secondes à la capnographie). Les critères d'évaluation secondaires comprenaient les variables hémodynamiques, la sédation, la sécurité des patient·es (scores composites des événements indésirables majeurs ou mineurs) et les issues indésirables au jour 7. RéSULTATS: Un événement respiratoire est survenu chez 89/98 (95 %) patient·es du groupe VNI et chez 69/97 (73 %) patient·es ayant un masque facial (risque relatif [RR], 1,29; intervalle de confiance [IC] à 95 %, 1,13 à 1,47; P < 0,001). Une hypoxémie est survenue chez 40 (42 %) patient·es du groupe VNI et chez 33 (34 %) patient·es ayant un masque facial (RR, 1,21 ; IC à 95 %, 0,84 à 1,74; P = 0,30). Une hypoxémie est survenue chez 40 (42 %) patient·es du groupe VNI et chez 33 (34 %) patient·es ayant un masque facial (RR, 1,21; IC 95 %, 0,84 à 1,74; P = 0,30). Les variables hémodynamiques, la sédation, les événements de sécurité majeurs ou mineurs et les issues pour les patient·es n'étaient pas différents entre les groupes. CONCLUSION: Les complications respiratoires étaient plus fréquentes chez les patient·es recevant une VNI sans aucun impact sur la sécurité ou les issues. Ces résultats n'appuient pas l'utilisation systématique de la VNI en peropératoire. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02779998); enregistrée le 4 novembre 2015.

Blood coagulation test abnormalities in trauma patients detected by sonorheometry: a retrospective cohort study.

Background: Traumatic hemorrhage guidelines include point-of-care viscoelastic tests as a standard of care. Quantra (Hemosonics) is a device based on sonic estimation of elasticity via resonance (SEER) sonorheometry to assess whole blood clot formation. Objectives: Our study aimed to assess the ability of an early SEER evaluation to detect blood coagulation test abnormalities in trauma patients. Methods: We conducted an observational retrospective cohort study with data collected at hospital admission of consecutive multiple trauma patients from September 2020 to February 2022 at a regional level 1 trauma center. We performed a receiving operator characteristic curve analysis to determine the ability of the SEER device to detect blood coagulation test abnormalities. Four values on the SEER device were analyzed: clot formation time, clot stiffness (CS), platelet contribution to CS, and fibrinogen contribution to CS. Results: A total of 156 trauma patients were analyzed. The clot formation time value predicted an activated partial thromboplastin time ratio of >1.5 with an area under the curve (AUC) of 0.93 (95% CI, 0.86-0.99). The AUC of the CS value in detecting an international normalized ratio of prothrombin time of >1.5 was 0.87 (95% CI, 0.79-0.95). The AUC of fibrinogen contribution to CS to detect a fibrinogen concentration of <1.5 g/L was 0.87 (95% CI, 0.80-0.94). The AUC of platelet contribution to CS to detect a platelet concentration of <50 G/L was 0.99 (95% CI, 0.99-1.00). Conclusion: Our results suggest that the SEER device may be useful for the detection of blood coagulation test abnormalities at trauma admission.

Early extubation in extracorporeal life support patients: A propensity score-matched study.

BACKGROUND: Extubation strategy in extracorporeal life support patients remains unclear, and literature only reports studies with significant biases. OBJECTIVES: To explore the prognostic impact of an early ventilator-weaning strategy in assisted patients after controlling for confounding factors. METHODS: A 10-year retrospective study included 241 patients receiving extracorporeal life support for at least 48 h, corresponding to a total of 977 days spent on assistance. The a priori probability of extubation for each day of assistance was calculated according to daily biological examinations, drug doses, clinical observations, and admission data to pair each day containing an extubation with one on which the patient was not extubated. The primary outcome was survival at day 28. The secondary outcomes were survival at day 7, respiratory infections, and safety criteria. RESULTS: Two similar cohorts of 61 patients were generated. Survival at day 28 was better in patients extubated under assistance in univariate and multivariate (HR = 0.37 [0.2-0.68], p-value = 0.002) analyses. Patients who underwent failed early extubation did not have a different prognosis from those without early extubation. Successful early extubation was associated with a better outcome than a failed or no attempt at early extubation. Survival at day 7 and the rate of respiratory infections were better in early-extubated patients. Safety data did not differ between the two groups. CONCLUSIONS: Early extubation during assistance was associated with a superior outcome in our propensity-matched cohort study. The safety data were reassuring. However, due to the lack of prospective randomized studies, the causality remains uncertain.

Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022.

BACKGROUND: Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN: A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS: These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION: Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION: All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.

Final Study Report of Andexanet Alfa for Major Bleeding With Factor Xa Inhibitors.

BACKGROUND: Andexanet alfa is a modified recombinant inactive factor Xa (FXa) designed to reverse FXa inhibitors. ANNEXA-4 (Andexanet Alfa, a Novel Antidote to the Anticoagulation Effects of Factor Xa Inhibitors) was a multicenter, prospective, phase-3b/4, single-group cohort study that evaluated andexanet alfa in patients with acute major bleeding. The results of the final analyses are presented. METHODS: Patients with acute major bleeding within 18 hours of FXa inhibitor administration were enrolled. Co-primary end points were anti-FXa activity change from baseline during andexanet alfa treatment and excellent or good hemostatic efficacy, defined by a scale used in previous reversal studies, at 12 hours. The efficacy population included patients with baseline anti-FXa activity levels above predefined thresholds (≥75 ng/mL for apixaban and rivaroxaban, ≥40 ng/mL for edoxaban, and ≥0.25 IU/mL for enoxaparin; reported in the same units used for calibrators) who were adjudicated as meeting major bleeding criteria (modified International Society on Thrombosis and Haemostasis definition). The safety population included all patients. Major bleeding criteria, hemostatic efficacy, thrombotic events (stratified by occurring before or after restart of either prophylactic [ie, a lower dose, for prevention rather than treatment] or full-dose oral anticoagulation), and deaths were assessed by an independent adjudication committee. Median endogenous thrombin potential at baseline and across the follow-up period was a secondary outcome. RESULTS: There were 479 patients enrolled (mean age, 78 years; 54% male; 86% White); 81% were anticoagulated for atrial fibrillation, and the median time was 11.4 hours since last dose, with 245 (51%) on apixaban, 176 (37%) on rivaroxaban, 36 (8%) on edoxaban, and 22 (5%) on enoxaparin. Bleeding was predominantly intracranial (n=331 [69%]) or gastrointestinal (n=109 [23%]). In evaluable apixaban patients (n=172), median anti-FXa activity decreased from 146.9 ng/mL to 10.0 ng/mL (reduction, 93% [95% CI, 94-93]); in rivaroxaban patients (n=132), it decreased from 214.6 ng/mL to 10.8 ng/mL (94% [95% CI, 95-93]); in edoxaban patients (n=28), it decreased from 121.1 ng/mL to 24.4 ng/mL (71% [95% CI, 82-65); and in enoxaparin patients (n=17), it decreased from 0.48 IU/mL to 0.11 IU/mL (75% [95% CI, 79-67]). Excellent or good hemostasis occurred in 274 of 342 evaluable patients (80% [95% CI, 75-84]). In the safety population, thrombotic events occurred in 50 (10%) patients; in 16 patients, these occurred during treatment with prophylactic anticoagulation that began after the bleeding event. No thrombotic episodes occurred after oral anticoagulation restart. Specific to certain populations, reduction of anti-FXa activity from baseline to nadir significantly predicted hemostatic efficacy in patients with intracranial hemorrhage (area under the receiver operating characteristic curve, 0.62 [95% CI, 0.54-0.70]) and correlated with lower mortality in patients <75 years of age (adjusted P=0.022; unadjusted P=0.003). Median endogenous thrombin potential was within the normal range by the end of andexanet alfa bolus through 24 hours for all FXa inhibitors. CONCLUSIONS: In patients with major bleeding associated with the use of FXa inhibitors, treatment with andexanet alfa reduced anti-FXa activity and was associated with good or excellent hemostatic efficacy in 80% of patients. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02329327.

Preoperative fibrinogen level and postcardiac surgery morbidity and mortality rates.

Background: High preoperative fibrinogen levels are associated with reduced bleeding rates after cardiac surgery. Fibrinogen is directly involved in inflammatory processes and is a cardiovascular risk factors. Whether high fibrinogen levels before cardiac surgery are a risk factor for mortality or morbidity remains unclear. Aims: This study aimed to examine the association between preoperative fibrinogen levels and mortality and morbidity rates after cardiac surgery. Settings and Design: This is a single-center retrospective study. Material and Methods: Patients (n = 1628) were divided into high (HFGr) and normal (NFGr) fibrinogen level groups, based on the cutoff value of 3.3 g/L, derived from the receiver operating characteristic (ROC) curve analysis. The primary outcome was the 30-day mortality rate. The rates of postoperative complications, including postoperative bleeding and transfusion rates, were examined. Statistical Analysis: Between-group comparisons were performed with the Mann-Whitney U test and Chi-squared test, as suitable. Model discriminative power was examined with the area under the ROC curve. Results: The HFGr and NFGr included 1103 and 525 patients, respectively. Mortality rate was higher in the HFGr than in the NFGr (2.7% vs. 1.1%, P = 0.04). The 12-h bleeding volume (280 mL [195-400] vs. 305 mL [225-435], P = 0.0003) and 24-h bleeding volume values (400 mL [300-550] vs. 450 mL [340-620], P < 0.0001) were lower in the HFGr than in the NFGr. However, the rate of red blood cell transfusion during hospitalization was higher in the HFGr than in the NFGr (21.7% vs. 5.9%, P = 0.0103). Major complications were more frequent in the HFGr than in the NFGr. Conclusion: High fibrinogen levels were associated with reduced postoperative bleeding volume and increased mortality and morbidity rates.

Management of urgent invasive procedures in patients treated with direct oral anticoagulants: An observational registry analysis.

BACKGROUND: Patients treated with direct oral anticoagulants (DOACs) may require urgent procedures. Managing these patients is challenging due to different bleeding risks and may include laboratory testing, procedural delays, or haemostatic/reversal agent administration. OBJECTIVE: We evaluated management strategies and outcomes of urgent, non-haemostatic invasive procedures in patients treated with DOACs. METHODS AND RESULTS: In a descriptive cohort study, we prospectively evaluated 478 patients in the GIHP-NACO registry, from June 2013 to November 2015. Hospitalised patients receiving dabigatran (n = 160), rivaroxaban (n = 274), or apixaban (n = 44) requiring urgent, procedural interventions were evaluated, of which 384/478 (80 %) were surgical procedures. Orthopaedic surgery included 216/384 patients (56 %), while gastrointestinal surgery included 75/384 (20 %) patients. On admission, the median age was 79 (70-85), and creatinine clearance was <60 mL·min-1 in 316/478 (66 %) patients. DOAC concentration was determined in 277 (58 %) patients and was 85 ng·mL-1 (median; range 0-764), 61 ng·mL-1 (3-541), and 81 ng·mL-1 (26-354) for dabigatran, rivaroxaban, and apixaban, respectively. Procedures were delayed in 194/455 (43 %) of the cases. Excessive bleeding was observed in 62/478 (13 %) procedures, and haemostatic agents were administered in 76/478 (16 %) procedures. By day 30, major cerebral and cardiovascular events were observed in 38/478 (7.9 %) patients, and mortality was 28/478 (5.9 %). CONCLUSIONS: In the GIHP-NACO registry, before specific antidotes were available, DOAC treated patients undergoing urgent invasive procedures were delayed in nearly half of the cases, and showed a low rate of excessive bleeding, suggesting that most urgent procedures can be performed safely without DOAC reversal. CLINICAL TRIAL REGISTRATION: www. CLINICALTRIALS: gov. Identifier: NCT02185027.

Guidelines for clothing in the operating theatre, 2021.

OBJECTIVE: To provide guidelines for the choice of items of clothing (except sterile surgical gown) for staff working in the operating theatre. DESIGN: A committee of nine experts from SFAR and the SF2H learned societies was convened. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. Likewise, it did not benefit from any funding from a company marketing a health product (drug or medical device). The authors were required to follow the rules of the GRADE® method (Grading of Recommendations Assessment, Development and Evaluation) to assess the quality of the evidence on which the recommendations were based. METHODS: We aimed to formulate recommendations according to the GRADE® methodology for four different fields: operating theatre suits, operating theatre hats, masks, and shoes/over-shoes. Each question was formulated according to the PICO format (Patient, Intervention, Comparison, Outcome). The literature review and recommendations were formulated according to the GRADE® methodology. RESULTS: The experts' synthesis work and their application of the GRADE® method resulted in 13 recommendations. As the GRADE® method could not be integrally applied to all questions, some recommendations were formulated as expert opinions. CONCLUSION: Based on strong agreement between experts, we produced 13 recommendations to guide the choice of operating theatre attire.

Redistribution of critical drugs in shortage during the first wave of COVID-19 in France: from operating theaters to intensive care units.

BACKGROUND: Tension in the supply of highly consumed drugs for patients with COVID-19 (propofol, midazolam, curares) led the French government to set up a centralized supply of hospitals with distribution based on the number of resuscitation beds in March 2020. The French Societies of Clinical Pharmacy and of Anesthesia and Critical Care aimed to evaluate the changes in total needs and the distribution between anesthesia and critical care activities (CCU), to prepare resumed surgical activity. METHODS: National declarative survey among pharmacists, via an online form (SurveyMonkey®), was conducted in April and May 2020. The analysis focused on quantities dispensed during the whole year 2019, and March and April of year 2019 and 2020 for the drugs subject to quota, and on their distribution in CCU and operating theaters. RESULTS: For the 358 establishments (47% public, 53% private), dispensations in CCU in March 2020 compared to March 2019 increased, respectively: propofol (+81%), midazolam (+125%), cisatracurium (+311%), atracurium (+138%), rocuronium (+119%); and decreased for anaesthesia: propofol (-27%), midazolam (-10%), cisatracurium (-19%), atracurium (-27%), rocuronium (+16%). CONCLUSIONS: Variation of dispensations between CCU and others was directly related to the increase of COVID patients in CCU and the decrease in surgical activity. Each establishment could receive up to five or six different presentations and concentrations, leading to a major risk of medication error. This collaborative national survey provided accurate data on the drugs' usual consumption. This work emphasized the need for a strong collaboration between pharmacists and anesthesiologists and intensive care physicians. It was further used by the Health Ministry to adjust the drug distribution.

Impact of a large interprofessional simulation-based training course on communication, teamwork, and safety culture in the operating theatre: A mixed-methods interventional study.

BACKGROUND: Communication and teamwork are critical non-technical skills in the operating theatre. However, prevention of events associated with communication failures by large simulation-based programs remains to be evaluated. The objective was to assess the impact of an interprofessional simulation-based training course on communication, teamwork, checklist adherence, and safety culture. METHODS: We aimed to assess the impact of an interprofessional simulation-based training course on communication, teamwork, checklist adherence, and safety culture. We conducted a before-and-after interventional study based on a mixed-methods approach combining qualitative and quantitative evaluation criteria. The study was performed in a University Hospital with 39 operating theatres operated by 300 providers before (period 1) and after (period 2) an interprofessional simulation-based training course. Surgical procedures were observed, and the primary outcome measure was the rate of procedures with at least one communication failure associated with adverse event. Additional outcomes measured included the rate of other communication failures, checklist adherence, while teamwork and safety culture were assessed by questionnaires. RESULTS: In total, 46 970 communication episodes were analysed during 131 (period 1) and 122 (period 2) surgical procedures. One hundred sixty-four professionals attended 40 simulation-based sessions. The rate of procedures with at least one communication failure associated with adverse events was not significantly different between the 2 periods (38% in period 1 and 43% in period 2; P = 0.47). Nevertheless, the rate of communication failures reduced between period 1 and 2 (8117/28 303 (29%) vs. 3868/18 667 (21%), respectively; P < 0.01). Teamwork scores and checklist adherence increased significantly after the intervention (8.1 (7.2-8.7) in period 1 vs. 8.6 (8.0-9.2) in period 2; P < 0.01 and 17% (0-35 %) in period 1 vs. 44% (26-57 %) in period 2; P < 0.01). Safety culture ratings did not change significantly. CONCLUSION: This study shows that although the rate of procedures with at least one communication failure associated with adverse event (primary endpoint) was not significantly different, a large interprofessional simulation-based training course has a positive effect on communication failures, teamwork, and checklist adherence.

Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices.

OBJECTIVE: Discuss if the use of disposable or reusable medical devices leads to a difference in terms of hospital-acquired infection or bacterial contamination. Determine which solution is less expensive and has less environmental impact in terms of carbon footprint, energy and water consumption and amount of waste. METHODS: We carried out a narrative review. Articles published in English and French from January 2000 to April 2020 were identified from PubMed. RESULTS: We retrieved 81 articles, including 12 randomised controlled trial, 21 literature reviews, 13 descriptive studies, 6 experimental studies, 9 life-cycle studies, 6 cohort studies, 2 meta-analysis, 4 case reports and 8 other studies. It appears that pathogen transmission in the anaesthesia work area is mainly due to the lack of hand hygiene among the anaesthesia team. The benefit of single-use devices on infectious risk is based on weak scientific arguments, while reusable devices have benefits in terms of costs, water consumption, energy consumption, waste, and reducing greenhouse gas emissions. CONCLUSION: Disposable medical devices and attire in the operating theatre do not mitigate the infectious risk to the patients but have a greater environmental, financial and social impact than the reusable ones. This study is the first step towards recommendations for more environmental-friendly practices in the operating theatre.

Initiatives to broaden safety concerns in anaesthetic practice: The green operating room.

The health sector is a major contributor to climate change through its large carbon footprint. Hospitals are highly energy and resource intensive. Operating rooms (ORs) contribute to a major part of these emissions because of anaesthetic gases, energy-intensive equipment and waste. Besides initiatives aimed to mitigate hospitals' climate footprints, health care professionals need to be involved in this process by changing their professional and personal behaviours without compromising the quality of care. Education on metrics (greenhouse gases), concepts (life cycle) and strategies to reduce the health care footprint would help professionals to commit themselves to the issue. The 5R's rule (reduce, reuse, recycle, rethink and research) used to promote an environmentally friendly way of life can be applied to the medical field and especially to the operating room and anaesthesia. When applied in the ORs, these strategies help question the use of disposable devices, attires and packaging, as well as our professional and personal behaviour. Greening the ORs requires the engagement of all professionals as well as other departments (pharmacy, hygiene) and management. Economic and social co-benefits are expected from this process.

Impact of High-Dose Prophylactic Anticoagulation in Critically Ill Patients With COVID-19 Pneumonia.

BACKGROUND: Because of the high risk of thrombotic complications (TCs) during SARS-CoV-2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent. RESEARCH QUESTION: What is the incidence of TC in critically ill patients with COVID-19 and what is the relationship between the dose of anticoagulant therapy and the incidence of TC? STUDY DESIGN AND METHODS: All consecutive patients referred to eight French ICUs for COVID-19 were included in this observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high-dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight. RESULTS: Of 538 patients included, 104 patients experienced a total of 122 TCs with an incidence of 22.7% (95% CI, 19.2%-26.3%). Pulmonary embolism accounted for 52% of the recorded TCs. High-dose prophylactic anticoagulation was associated with a significant reduced risk of TC (hazard ratio, 0.81; 95% CI, 0.66-0.99) without increasing the risk of bleeding (HR, 1.11; 95% CI, 0.70-1.75). INTERPRETATION: High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill patients with COVID-19 without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT04405869; URL: www.clinicaltrials.gov.