Anaesthesia and intensive care management of face transplantation.

The face-grafting techniques are innovative and highly complex, requiring well-defined organization of all the teams involved. Subsequent to the first report in France in 2005, there have been 17 facial allograft transplantations performed worldwide. We describe anaesthesia and postoperative management, and the problems encountered, during the course of seven facial composite tissue grafts performed between 2007 and 2011 in our hospital. The reasons for transplantation were ballistic trauma in four patients, extensive neurofibromatosis in two patients, and severe burns in one patient. Anaesthesia for this long procedure involves advanced planning for airway management, vascular access, technique of anaesthesia, and fluid management. Preparation and grafting phases were highly haemorrhagic (>one blood volume), requiring massive transfusion. Median (range) volumes given for packed red cell (PRC) and fresh-frozen plasma (FFP) were 64.2 ml kg(-1) (35.5-227.5) and 46.2 ml kg(-1) (6.3-173.7), respectively. Blood loss quantification was difficult because of diffuse bleeding to the drapes. The management of patients with neurofibromatosis or burns involving the whole face was more difficult and haemorrhagic than the patients with lower face transplantation. Average surgical duration was 19.1 h (15-28 h). Postoperative severe graft oedema was present in most patients. Most patients encountered complications in ICU, such as renal insufficiency, acute respiratory distress syndrome, and jugular thrombosis. Opportunistic bacterial infections were a feature during the postoperative period in these highly immunosuppressed patients.

[Systemic analgesia for postoperative pain management in the adult]. / Analgésie par voie générale pour la prise en charge des douleurs postopératoires chez l'adulte.

Severe postsurgical pain contributes to prolonged hospital stay and is also believed to be a risk factor for the development of chronic pain. Locoregional anesthesia, which results in faster patient recovery with fewer side effects, is favored wherever feasible, but is not applicable to every patient. Systemic analgesics are the most widely used method for providing pain relief in the postoperative period. Improvements in postoperative systemic analgesia for pain management should be applied and predictive factors for severe postoperative pain should be anticipated in order to control pain while minimizing opioid side effects. Predictive factors for severe postoperative pain include severity of preoperative pain, prior use of opiates, female gender, non-laparoscopic surgery, and surgeries involving the knee and shoulder. Pre- and intraoperative use of small doses of ketamine has a preventive effect on postoperative pain. Multimodal or balanced analgesia (the combined use of various analgesic agents) such as NSAID/morphine, NSAID/nefopam, morphine/ketamine improves analgesia with morphine-sparing effects. Nausea and vomiting, the principle side effects of morphine, can be predicted using Apfel's simplified score; patients with a high Apfel score risk should receive preemptive antiemetic agents aimed at different receptor sites, such as preoperative dexamethasone and intraoperative droperidol. Droperidol can be combined with morphine for postoperative patient-controlled anesthesia (PCA). When PCA is used, dosage parameters should be adjusted every day based on pain evaluation. Patients with presurgical opioid requirements will require preoperative administration of their daily opioid maintenance dose before induction of anesthesia: PCA offers useful options for effective postsurgical analgesia using a basal rate equivalent to the patient's hourly oral usage plus bolus doses as required.

[Cardiac papillary fibroelastoma and stroke during pregnancy: Case report]. / AVC révélant un fibroélastome pendant la grossesse : case report.

Stroke occurring during pregnancy is linked to high mortality. Stroke may be directly related to pregnancy (e.g. eclampsia, cerebral venous thrombosis), but all the other causes of stroke are possible. Brain magnetic resonance imaging that is not contraindicated during pregnancy remains the reference in this context. We report the case of a woman with severe headache associated with visual disturbances, without hypertension or proteinuria at 32 weeks of pregnancy. MRI revealed multiple recent cerebral vascular accidents. An echocardiogram detected a papillary fibroelastoma of 5mm. Maternal fetal experts determined it safe to continue the pregnancy. Childbirth at 39 weeks was normal uneventful for the newborn and mother. In the postpartum, despite the theoretical operative indication to resect the small residual papillary fibroelastoma, the patient was followed expectantly because of the stable neuro-cardiologic state. A fibroelastoma can be revealed by a stroke during pregnancy. In the postpartum period, an expectant attitude can be reasonably chosen in case of small size of the fibroelastoma.

Impact of written information describing postoperative pain management on patient agreement with proposed treatment.

BACKGROUND AND OBJECTIVES: Because patients who are to undergo surgery must give their consent to planned postoperative care, clear and complete information on postoperative pain management should be given. The aim of this quality-of-care study was to evaluate by inquiry the impact of written information describing postoperative pain management on the quality and type of information retained, and patient participation in discussing and agreeing to the postoperative pain management programme during the presurgical anaesthesiology consultation. METHODS: Prospective before and after interventional surveys, each lasting 3 weeks and conducted at a 6-month interval (time required to prepare the written information), used a standardized anonymous questionnaire given to patients after the anaesthesiology consultation. Questions requiring a 'yes' or 'no' response assessed the quality of information and what information was retained by the patient, the extent of the patient's interaction during the discussion with the anaesthesiologist and his/her agreement with the postoperative pain management programme. RESULTS: Among the 180 before-group patients included, 16.7% reported receiving verbal information during the anaesthesiology consultation, none retained all seven principal side-effects of morphine, 14.4% considered the information to be thorough, 20.6% understood it, 16.7% claimed that it had helped them participate in the discussion and 14.4% concurred with the postoperative pain management programme. Compared to the before inquiry, significantly higher percentages of the 107 after-group patients (given written information before the anaesthesiology consultation) responded as having received verbal information during the anaesthesiology consultation (57.0%), retained morphine's main side-effects (12.1%), deemed the information thorough (58.9%) and understandable (53.3%), had participated in the discussion (47.7%) and agreed with the postoperative pain management programme (51.4%). CONCLUSION: Written information on postoperative pain management distributed before the presurgical anaesthesiology consultation improved the quality of information retained, facilitated discussion with the anaesthesiologist and patient agreement with the postoperative pain management programme.

[Pain management in subarachnoid haemorrhage: a survey of French analgesic practices]. / Prise en charge des céphalées secondaires aux hémorragies sous-arachnoïdiennes dans les centres de neurochirurgie français.

OBJECTIVE: Pain management in patients having a subarachnoid haemorrhage was assessed in French intensive care unit of neurosurgical centres. STUDY DESIGN: Nationwide survey. METHODS: A standardized postal questionnaire was sent to senior doctor of every neurosurgical centres in France inquiring pain scores assessment, analgesics used and their routes of administration, centre's opinion about efficacy of pain management. RESULTS: Of the 34 centres, 24 returned completed questionnaires. Fifty four per cent of the centres evaluated pain intensity with a non valid pain score. In the case of patients in the comatose, pain was not evaluated in fifty four per cent of the centres. Paracetamol and morphine were the most currently used analgesics drugs. Morphine was administered subcutaneously by 75% of the centres. Six centres used also PCA. Thirty-seven percent of the centres were reluctant to use opioids and 75% to use NSAIDS. CONCLUSION: The majority of the centres considered pain management in patient suffering from subarachnoid haemorrhage (SAH) was not optimal and stressed the need to establish a well validated pain rating scale dedicated to SAH patients.

[Dose-dependent vasodilator effect of dobutamine in calves with a constant cardiac output artificial heart]. / Effet vasodilatateur dose-dépendant de la dobutamine chez le veau sous coeur artificiel à débit cardiaque constant.

The haemodynamic effect of any drug being the resultant of its myocardial and vascular actions, it is often difficult to separate what is due to each of these components. Dobutamine is regarded as having an almost exclusive effect on the myocardium in therapeutic doses (1); its administration after implantation of an artificial heart would enable its peripheral vascular effects to be determined by exclusion of the native ventricles. Experiments were conducted on three calves weighing about 90 kg each. The artificial heart, two central venous catheters and a femoral arterial catheter were implanted under general anaesthesia. The study began on the first post-implantation day, the animals being awake, in stable haemodynamic status and with normal temperature. Dobutamine was infused through one of the venous catheter placed in the native atrium, in 6 stepwise doses of 5, 10, 15, 20, 25 and 30 mcg/kg/min, each dose being given over 10 min and separated from the other dose by a 10 min interval. The order in which these doses were administered was determined at random. By adjusting the propulsion pressure of the two ventricles and the heart rate, the cardiac output was set at a fixed value of 7.85 L/min throughout the study, this value being controlled by a computer-assisted unit. Right atrial pressure and femoral arterial were recorded during each step of the infusion. Total peripheral resistance was calculated over a stable period of the last 5 min of each dosing and before administration of dobutamine. This procedure was repeated 4 times in each calf, at intervals of 24 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

[Implantation of an artificial heart of Jarvik's type for awaiting a new cardiac transplantation in acute rejection]. / Implantation d'un coeur artificiel de type Jarvik dans l'attente d'une nouvelle transplantation cardiaque au cours d'un rejet aigu.

The implantation of an artificial Jarvik-type artificial heart while awaiting retransplantation raises a technical problem which has not yet been definitively solved. An original technique which consists of preserving the atrial portion of the graft and its vessels is presented and illustrated by a clinical case.

[French survey on perioperative nutrition in cirrhotic adult patients waiting for liver transplantation]. / Enquête sur l'évaluation et la prise en charge nutritionnelle des patients adultes cirrhotiques candidats à une transplantation hépatique.

OBJECTIVE: The European Society for Clinical Nutrition and Metabolism (EPSEN) guidelines on nutrition for liver disease patients has been recently updated. The aim of our study was to evaluate perioperative nutrition in cirrhotic patients waiting for liver transplantation (LT). STUDY DESIGN: Prospective electronic survey. A standardized questionnaire was sent to the anaesthesiologist of the 18 French adult LT centers. The questionnaire had closed-ended questions to evaluate nutritional practices in cirrhotic patients waiting for a LT. RESULTS: The response rate was 100%. Nutritional status of the cirrhotic patients waiting for LT was assessed by anaesthesiologists (12 centres) and/or hepatologists (11 centres) and more rarely by nutrition physician, dietetics or liver surgeons. Body mass index (13 centres), weight loss (10 centres), albuminemia (10 centres) were the most frequent items used to assess the nutritional status. Before LT, preoperative oral intakes were administered in undernourished patients in only 55% of the cases. Postoperatively, nutritional support was administered between day 1 and 3 after LT. CONCLUSION: Perioperative nutritional practices in cirrhotic patients waiting for LT are heterogeneous between centers, especially about nutrition assessment. Most of the centres did not follow the actual guidelines.

[Postoperative pain management on surgical wards; impact of using a validated reference tool in a short, medium and long term]. / Évaluation des pratiques professionnelles de la prise en charge de la douleur postopératoire à court, moyen et long terme.

OBJECTIVES: To evaluate the short medium and long-term impact of a quality-improvement program (QIP) in a university hospital using a validated reference tool. METHODS: Seven surgical departments were audited before and after implementation of a QIP in postoperative pain management. Audits were conducted in 2005, 2007, 2009 and 2012. In each audit, 10 medical charts from each surgical department were analyzed for 9 quality criteria. A surgical department score (SDS) was calculated for each department (maximum score=90). The surgical departments with a SDS<45 received targeted training sessions. RESULTS: In 2005, three surgical departments had a SDS<45. After the first audit, a targeted training sessions was conducted in the three surgical departments, all seven departments improved their scores with a SDS>45 in 2007. Between 2007 and 2009, all seven departments improved their scores. Conversely, between 2009 and 2012, the SDS diminished in six of the seven surgical departments and four of the nine evaluated quality criteria decreased significantly: right detailed order for postoperative pain analgesia (prescriber identifier, agent used, unit doses, mode of administration; 100% versus 53; P=0.027), appropriate dosing of steps I and II analgesics (96% versus 80%; P=0.041), morphine (90% versus 76%; P=0.039), based on corresponding physician orders and monitor morphine side effects (87% versus 29; P=0.027). CONCLUSION: Audits should be performed regularly (at least every two years) for detecting postoperative pain management degradation. Lack of targeted training sessions can explain partially this degradation.

[Wound infiltration with local anesthetics for postoperative analgesia. Results of a national survey about its practice in France]. / Infiltrations d'anesthésiques locaux pour l'analgésie postopératoire chez l'adulte. Résultats d'une enquête nationale de pratique.

BACKGROUND AND OBJECTIVE: Local wound infiltration is a component of multimodal postoperative (p.o.) analgesia. Its implementation in current clinical practice remains unknown. Pain and Regional Anesthesia Committee of the French Anaesthesia and Intensive Care Society (Sfar) aimed to appraise its practice. METHOD: Postal sample survey based on representative sample of national activity were sent to heads of anaesthesiology departments. The questionnaires included 36 items on single-shot and continuous wound infiltrations (CWI) with considerations about modality of administration, drugs and development limitations. Results in mean [CI95 %]. RESULTS: Response rate was 32 % (n=120). Sample was in accordance with national representation of health institutions. Local infiltration was included in 85 % [79-91] of the p.o. analgesia protocols. Regardless of the surgery, single-shot wound infiltration and CWI were used in more than 50 % of the patients by respectively 58 % [49-67] and 18 % [11-25] of the responders. However, a significant part of the surgeons remained reluctant to CWI. Lack of information and fear of septic complications were the most reported barriers. Peritoneal instillation after laparoscopy was rarely performed, in contrast with intra-articular infiltration after knee arthroscopy, performed systematically or very frequently by 60 % [50-70] of the responders. CONCLUSION: The practice of local wound infiltration for p.o. analgesia seems presently well established, especially for single-shot injections. CWI is less commonly performed. Several surgical reluctances remain to be overcome. Better information about effectiveness and safety are likely to still improve their practices.

Predictors of catheter-related bladder discomfort in the post-anaesthesia care unit.

BACKGROUND: Catheter-related bladder discomfort (CRBD) is often reported to be stressful and resistant to conventional opioid therapy in the post anaesthesia care unit (PACU). Tolterodine or oxybutynin or gabapentin given orally 1 hour before induction reduce the incidence and severity of CRBD postoperatively. Nevertheless, side effects may occur with these drugs. Thus, preadministration of these different drugs should be selective in patients with predictors of moderate or severe CRBD. The goal of this study was to determine the incidence and predictors of early postoperative CRBD in post-anesthesia care unit. METHODS: We designed a prospective observational study in two teaching hospitals. Consecutive adult patients undergoing surgery under general anaesthesia necessitating intraoperative urinary catheterization were included during a 6-month period. Bladder discomfort was assessed with a simple four-step severity scale: no pain; mild pain (revealed only by interviewing the patient); moderate (a spontaneous complaint by the patient) and severe discomfort (agitation, loud complaints and attempt to remove the bladder catheter). Predictors of CRBD were identified by univariate and multivariate analysis. RESULTS: 164 patients were included, of which 47% complained of CRBD (mild CRBD: 20%; moderate or severe CRBD: 27%). Multivariate logistic regression analysis showed the diameter of the Foley catheter superior than 18 G Fr (OR=2.2, CI95 [1.0-5.1], P=0.06) and male gender (OR=3.2, CI95 [1.0-10.5], P<0.06) to be independent predictors of moderate or severe CRBD in the PACU. CONCLUSION: This observational study identified the incidence and predictive factors of moderate and severe CRBD in the PACU. Future studies are warranted to assess the impact of preoperative antimuscarinic drugs or Gabapentin on males or patients with 18 G Fr Foley catheters.

[Prophylactic anti-emetic strategy: prevention among obstetrician-gynaecologists anaesthesia]. / Prévention des nausées et vomissements postopératoires : enquête sur les pratiques en chirurgie gynécologique auprès des membres du Club d'anesthésie réanimation en obstétrique.

OBJECTIVES: A prophylactic anti-emetic strategy should depend on the number of nausea and vomiting risk factors. This study was undertaken to evaluate the practices of postoperative nausea and vomiting (PONV) prevention practices among obstetrician-gynaecologists, anaesthetists. STUDY DESIGN: A prospective, self-administered questionnaire survey was emailed to all Club d'Anesthésie Réanimation Obstétricale (Caro) members (French Obstetric and Gynaecology Anaesthetists' Association). METHODS: The questionnaire had closed-ended questions to evaluate each Caro member's prophylactic anti-emetic practices. Questions concerned demographic datas, prophylactic anti-emetic drugs administered to the patients with or without well known risk factors for developing PONV, the existence of protocol to prevent PONV in their own department of anaesthesiology and their awareness of the existence of French Society of Anaesthesia and Intensive Care (Sfar) PONV prevention guidelines 2007. RESULTS: Of 115 questionnaires, 66 respondents (57%) returned the questionnaires. Most of the respondents (74%) worked in a university hospital. Forty-two percent practiced exclusively in obstetric-gynaecology department. Fifty-six percent were anaesthetists for more than 20 years. Eighty-five percent of the physicians were well-informed about the SFAR's PONV prevention guidelines. Thirty seven percent of respondents assessed Apfel score systematically for all their patients. The percentages, which didn't calculate the probability of PONV with Apfel score or calculated only in cases of PONV history or travel sickness were 18% and 45% respectively. In cases of two or more risk factors, 63% used droperidol, dexamethasone and ondansetron in double or triple combinations. CONCLUSIONS: Although most surveyed practitioners were well informed about the new guidelines concerning PONV prevention, 27% not follow these guidelines regarding the administration of anti-emetic drugs. The calculation of Apfel score in the preoperative period must be also strengthened.

[Patient dissatisfaction with postoperative pain: what are the main reasons?]. / Incidences et causes d'insatisfaction des patients vis-à-vis de la prise en charge de la douleur postopératoire.

INTRODUCTION: Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief. OBJECTIVE: To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48h postoperative period. PATIENTS AND METHODS: The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patient's satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons. RESULTS: Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period. CONCLUSION: There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.

[Nociceptive cancer pain in adult patients: statement about guidelines related to the use of antinociceptive medicine]. / Douleurs cancéreuses par excès de nociception chez l'adulte: mise au point sur les recommandations concernant les traitements antalgiques médicamenteux.

OBJECTIVE: The World Health Organization (WHO) published guidelines to improve cancer pain control which allow to relieve noceptive cancer pain in 80% of adult patients. Nevertheless WHO recommendations do not include: various ways to start morphine treatment, how to manage opioids adverse effects, severe cancer pain management, postoperative pain and procedure-relatived pain. The goal of this review is to discuss these issues. DATA SOURCES: The data were retrieved from PubMed years 2001 to 2006 (keywords used alone or in combination were: opioids, cancer, pain, pain killers, rotation, intraspinal, ketamine, side effects), the "Standard, Options and Recommendations on cancer nociceptive pain treatments for adult patients" published by the French Union of Comprehensive Cancer Centers (FNCLCC; Fédération nationale des centres de lutte contre le cancer) and the European Association for Palliative Care (EAPC) recommendations on morphine and alternative opioids in cancer pain. Data also include an analysis of studies before 2001 which give information about the pharmacokinetic data of transdermal and transmucosal fentanyl. STUDY SELECTION: Studies written in English or French related to the medical treatments (commercialized in France) for nociceptive cancer pain for adult patients were analyzed. Analyzed articles were clinical or experimental studies or metaanalyses. Studies on neuropathic cancer pain, editorials and letters to the editor were discarded. RESULTS: Nociceptive cancer pain is characterized by its frequent instability. More than 50% of patients have paroxystic painful accesses (PPA), either spontaneous or induced by care or mobilizations. Morphine is the main treatment but the prescription of controlled-release morphine must be associated with the prescription of immediate-release morphine to treat the PPA or to transmucosal fentanyl which has a faster onset of action than immediate-release morphine. Morphine treatment can be introduced either by immediate-release morphine or by controlled-release morphine. The introduction of immediate-release morphine is recommended for old or fragile patients, patients with denutrition, hepatic or renal failure. For patients suffering unbearable side effects under morphine or morphine resistant pain, opioid rotation or intravenous morphine or fentanyl are recommended. Spinal opioids administration (by epidural or intrathecal routes) is most often indicated in patients with very severe and resistant pain in terminal disease. In the postoperative period, previous pain treatment must be maintained or increased. Pain bounded to care procedures must be prevented with various and associated treatments: for example, mixed topics lidocaïne-prilocaine for venous or arterial punctures; infiltration of local anaesthetics and inhalation of an oxygen - nitrous oxide mixture for medullary biopsies. CONCLUSION: Oral immediate or controlled release morphine is the most common and effective pain treatment for most patients with nociceptive cancer pain but rotation with other opioids or alternative routes of administration must be discussed quickly if pain persits or if adverse effects occur.