Reducing tidal volume and increasing positive end-expiratory pressure with constant plateau pressure during one-lung ventilation: effect on oxygenation.

BACKGROUND: It is no longer safe to use large tidal volumes (V(T)) (>8 ml kg(-1)) for one-lung ventilation (OLV), and limiting plateau pressure should be a major objective. Due to the specificity of OLV, the use of positive end-expiratory pressure (PEEP) remains controversial. This study determined whether at the same low plateau pressure, reducing V(T) and increasing PEEP were not inferior to larger V(T) and lower PEEP ventilation in terms of oxygenation. METHODS: This prospective, randomized, non-inferiority, cross-over trial included 88 patients undergoing open thoracotomy who received two successive ventilatory strategies in random order: V(T) (8 ml kg(-1) of ideal body weight) with low PEEP (5 cm H(2)O), or low V(T) (5 ml kg(-1)) with a high PEEP. Respiratory rate and PEEP were, respectively, adjusted to maintain constant ventilation and plateau pressure. The primary endpoint was the ratio under each ventilatory strategy. RESULTS: The non-inferiority of low-V(T) ventilation could not be established. The mean adjusted ratio was lower overall during low-V(T) ventilation, and differences between the two ventilatory modes varied significantly according to baseline (T0). Decreased oxygenation during low V(T) was smaller when baseline values were low. Systolic arterial pressure was not lower during low-V(T) ventilation. CONCLUSION: During OLV, lowering V(T) and increasing PEEP, with the same low plateau pressure, reduced oxygenation compared with larger V(T) and lower PEEP. This strategy may reduce the risk of lung injury, but needs to be investigated further.

[Use of levosimendan in children]. / Utilisation du levosimendan chez l'enfant.

Levosimendan is a calcium-sensitizing drug with positive inotropic properties. As an inodilator, this molecule also has a vasodilation effect. While its efficacy has been demonstrated in the adult in the context of cardiac surgery, its pediatric use is still not widespread. Many studies have shown its safety of use in children, including in the newborn. Across the world, a growing number of teams use levosimendan to treat both acute and chronic heart failure. Through a review of the literature, we describe its pharmacodynamic effects, its current applications, and its perspectives of use in children.

[Anesthesia for non-cardiac surgery after Fontan repair]. / Anaesthésie après une opération de Fontan.

The considerable progress, performed for more than 30 years, in paediatric and interventional cardiology, imaging, surgery, anaesthesia and critical care in the congenital heart diseases allowed the survival the adulthood of more than 85 % of the affected children. The univentricular repair in total cavopulmonary connection or Fontan procedure, are realized in three stages, now, before the age of 5 years, with a different physiology after each stage. This point makes anaesthetic care more complicated for a non-cardiac surgery. The precise knowledge of the physiology of the "Fontan" is necessary before proceeding with anaesthesia. It allows to anticipate the pitfalls and to define specific strategies to be applied.

Impact of a long specialized training in anaesthesia on the quality of care in a developing country: experience in Laos.

OBJECTIVES: Assess the impact on the quality of practices in a developing country (Lao Democratic People's Republic) of a long specialized course in anaesthesia (Certificate of Specialized Studies in Anesthesia-Intensive care and Emergency Medicine [Cesarmu]) versus accelerated trainings. POPULATION AND METHOD: Study concerned all surgical hospitals and all anaesthesiologists of Lao PDR. At hospital level, the quality of care was assessed and compared between hospitals with and without Cesarmu anaesthetists by using the quality of anaesthesia record and the spinal anaesthesia frequency in lower gyneco-obstetrical surgery. On an individual level, we assessed and compared anaesthetists who were Cesarmu trained and those who were not by using theoretical and practical scores. The latter were acquired by observing complete perisurgical care (pre-, per- and postoperative practical scores). RESULTS: We visited 29 of the 34 surgical hospitals in Lao PDR and met 90 of the 111 anesthesiologists. At hospital level, quality criteria were higher in the group of hospitals with Cesarmu anaesthesiologists without that difference being significant. On the other hand, all individual scores measured were significantly higher in the Cesarmu group. DISCUSSION: The improvement of practices resulting from training was obvious at the individual level but its impact at hospital level was not significant. There were most likely not enough trained anaesthetists to significantly influence practices in their departments. CONCLUSION: According to the criteria used, the impact of Cesarmu on the quality of anaesthesia in Lao PDR seems positive. However, training needs to be continued and practices homogenized.

[Effectiveness of a recruitment manoeuvre and positive end-expiratory pressure on respiratory mechanics during laparoscopic bariatric surgery]. / Efficacité d'une manoeuvre de recrutement alvéolaire associée à une pression expiratoire positive sur la mécanique respiratoire en coeliochirurgie bariatrique.

OBJECTIVE: To evaluate recruitment manoeuvre (RM) efficiency associated with a 10 cmH(2)O positive end expiratory pressure (PEEP) on respiratory mechanic estimated by lung compliance (Ctp) and PEEP to ZEEP expiratory volume delta (Delta VTE) during laparoscopic bariatric surgery in patients with morbid obesity. STUDY DESIGN: Prospective randomized study. METHODS: Twenty-six obese patients (BMI>40 kg/m(2)) undergoing laparoscopic bariatric surgery. The recruitment group received an RM followed by a 10 cmH(2)O PEP versus only 10 cmH(2)O PEP in the control group. Ctp was measured during the intervention and functional residual capacity (FRC) was estimated measuring Delta VTE during a PEP to ZEP manoeuvre. Mann and Whitney tests as well as a t-test were used (significance p<0.05). RESULTS: In the RM group, a significant improvement of 52+/-14 ml/cmH(2)O was noted versus a 36+/-10 ml/cmH(2)O in the PEP group (p=0,004). This improvement was transitory and no statistically significant Delta VTE difference was noted between the groups at the end of the intervention (360 [90-770]ml [MRA] and 310 [190-450]ml [PEP]). CONCLUSION: In patients with morbid obesity undergoing laparoscopic bariatric surgery, an RM conducted prior the pneumoperitoneum temporarily improves lung mechanics but without any change of the end expiratory lung volume at the end of the surgery in comparison with PEP alone. The RM was well tolerated.

[Pupillary dilatation monitoring to evaluate acute remifentanil tolerance in cardiac surgery]. / Monitorage de la dilatation pupillaire dans l'évaluation d'une tolérance aiguë au rémifentanil en chirurgie cardiaque.

INTRODUCTION: Remifentanil is a powerful morphinic agonist often ordered for anaesthesia. The use of peroperative large doses of this opioid increases the risk to develop postoperative hyperalgesia and acute tolerance. But how early these effects can occur? Despite the fact that these effects could be masked during the preoperative time because of general anaesthesia, it seems they could occur precociously. In order to try to describe this time, this study evaluated the acute tolerance under general anaesthesia requiring large doses of remifentanil by using an effective peroperative monitoring of nociception: the continuous pupillary diameter monitoring. MATERIALS AND METHODS: In this prospective observational clinical study, a continuous infusion of remifentanil was started at a range of 0.3 microg/kg/min after induction of anaesthesia by using propofol (TIVA), remifentanil bolus and cisatracurium. The pupil monitoring started 10 min later (T+10 min) and lasted until the surgical incision (T+65 min). So, there was no surgical stimulus during this time. RESULTS: Thirty patients undergoing major cardiac or vascular surgery were included in this study. The continuous pupil diameter evaluation showed a significant increase of the pupil diameter from T+45 min. No significant variation of heart rate, blood pressure, bispectral index (BIS) values were observed. DISCUSSION: The development of acute remifentanil tolerance could possibly explain these results. If evaluations with continuous pupillary diameter monitoring are still limited, these results suggest that the use of powerful opioids such as remifentanil should be associated with a N-methyl-D-aspartate (NMDA) receptor antagonist agent, including short time administrations.

[Cranial subdural haematoma after spinal anaesthesia treated by blood patch]. / Hématome sous-dural aigu intracrânien après rachianesthésie traité par blood patch.

The authors report a case of subdural haematoma after spinal anaesthesia. A 36-year-old woman underwent phlebectomy under spinal anaesthesia. Two days later, she complains of severe headache without neurological signs, not responding to bed rest and analgesics. Magnetic resonance imaging showed a small acute subdural haematoma in the right parieto-occipital region. On the forth day, she was given a blood-patch, which improved rapidly the patient. Recovery was complete.

[Congenital factor VII deficiency and subarachnoidal haemorrhage due to intracranial aneurysm: a case report]. / Hémorragie sous-arachnoïdienne par rupture d'anévrisme et déficit en facteur VII, à propos d'un cas.

The management of subarachnoid haemorrhage by aneurysm rupture is well codified. Some rare cases can be problematical. We report a case of a patient suffering from factor VII (FVII) deficiency who presented a subarachnoid haemorrhage by sylvian aneurysm rupture. The bleeding risk was prevented by plasmatic factor VII substitution and aneurysm coiling. Anticoagulation in order to prevent from thromboembolic risk after embolisation was started for 36 hours, associated with plasmatic FVII substitution (with an objective of plasmatic FVII rate of 30%). After this stage at high thromboembolic risk, there has been no shift to platelet antiaggregants and FVII substitution was stopped. The outcome at 1 month was propitious without any bleeding nor arterial thrombosis.

Diffusion MRI in spinal dural arterio-venous fistula: a case report.

STUDY DESIGN: Case report. OBJECTIVES: Brain diffusion magnetic resonance imaging (MRI) and apparent diffusion coefficient (ADC) maps are useful to differentiate vasogenic and cytotoxic oedema during cerebovascular diseases. We investigate spinal cord diffusion MRI and ADC maps before and after treatment in one case of spinal dural arteriovenous fistula. SETTING: University of Bordeaux, France. METHODS: We used spinal cord diffusion MRI. RESULTS: We found a vasogenic oedema that disappears after treatment. CONCLUSION: This case report confirms the interest of spinal cord diffusion and ADC maps to differentiate vasogenic and cytotoxic oedema at the spinal cord level.