Postreperfusion syndrome during liver transplantation for cirrhosis: outcome and predictors.

During orthotopic liver transplantation (OLT), a marked decrease in blood pressure following unclamping of the portal vein and liver reperfusion is frequently observed and is termed postreperfusion syndrome (PRS). The predictive factors and clinical consequences of PRS are not fully understood. The goal of this study was to identify predictors of PRS and morbidity/mortality associated with its occurrence during OLT in patients with cirrhosis. During a 3-year period, all consecutive OLT procedures performed in patients with cirrhosis were studied. Exclusion criteria were OLT for acute liver failure, early retransplantation, combined liver/kidney transplantation, and living-donor related transplantation. PRS was defined as a decrease in the mean arterial pressure of more than 30% of the value observed in the anhepatic stage, for more than 1 minute during the first 5 minutes after reperfusion of the graft. Transplantation was performed with preservation of the inferior vena cava with or without temporary portocaval shunt. Associations between PRS and donor and recipient demographic data, recipient operative and postoperative outcomes were tested with bivariate statistics. Independent predictors of PRS were determined in multivariable logistic regression analysis. Of the 75 patients included in the study, 20 patients (25%) developed PRS. In a multivariable analysis, absence of a portocaval shunt [odds ratio (95% confidence interval) = 4.42 (1.18-17.6)] and duration of cold ischemia [odds ratio (95% confidence interval) = 1.34 (1.07-1.72)] were independent predictors of PRS. Patients who experienced PRS displayed more postoperative renal failure and lower early (<15 days after OLT) survival (80% versus 96%; P = 0.04). In conclusion, the absence of portocaval shunt and the duration of cold ischemia were independent predictors of intraoperative PRS. PRS was associated with significant adverse postoperative outcome. These results provide realistic clinical targets to improve patient outcome after OLT for cirrhosis.

Individual probability of allogeneic erythrocyte transfusion in elective spine surgery: the predictive model of transfusion in spine surgery.

BACKGROUND: The aim of this study was to generate a score based on preoperative characteristics and predictive of the individual probability of allogeneic erythrocyte transfusion in patients undergoing elective thoracolumbar spine surgery. METHODS: Two hundred thirty consecutive patients were retrospectively included over a 15-month period (derivation set). Preoperative independent predictors of erythrocyte transfusion from the day of surgery until postoperative day 5 were determined by multivariable analysis, from which a model of individual probability of transfusion was derived and prospectively validated in 125 additional patients (validation set). RESULTS: Four preoperative independent predictors were associated with transfusion: age older than 50 yr (adjusted odds ratio = 4.9 [2-13.5]), preoperative hemoglobin level less than 12 g/dl (adjusted odds ratio = 6.9 [3.1-17.2]), fusion of more than two levels (adjusted odds ratio = 6.7 [3.1-15.2]), and transpedicular osteotomy (adjusted odds ratio = 19.9 [5.6-98.2]). A 0-4 score (0 = no risk, 4 = maximum risk) predictive of allogeneic transfusion was derived by weighting estimate parameters for each variable in a multivariable logistic regression model. Discriminating capacity of the score was 0.86 [0.81-0.92] in the receiver operating characteristics in the derivation sample and 0.83 [0.75-0.91] in the validation sample. The observed transfusion rates in the validation set and the individual probabilities of erythrocyte transfusion from the score were well correlated (y = 0.98x + 0.04; P < 0.0001), and the observed differences were not statistically different (goodness-of-fit chi-square, P = 0.125). The score was also correlated with the number of erythrocyte units transfused (Spearman rho = 0.61; P < 0.0001). CONCLUSION: The Predictive Model of Transfusion in Spine Surgery may be useful in clinical practice to identify patients undergoing spine surgery at risk of massive bleeding and encourage erythrocyte-saving strategies in these patients.

[Anesthesiologists in France].

We review some anesthesiologist's curriculum and demographic characteristics in France to the community of Japanese anesthesiologists. To become a certified anesthesiologist and an intensive care physician currently requires six years' medical education, passing national medical examination, and five years' special training as an intern of anesthesiology and intensive care. This educational course was started in 1984. There are 7942 certified anesthesiologists in France in 1999. The average age is 45.9 years and the ratio of female is 35.3%. Approximately two thirds of certified anesthesiologists are working in public institutions. 89% is full-time workers. More than half of certified anesthesiologists actually participate in daily intensive care practice. The number of certified anesthesiologists has been increasing gradually totaling 10,062 persons in 2005. The number of certified anesthesiologists per ten thousands general population is 1.7 persons and the corresponding ratio to all medical doctors is 4.8%. Working hours and holidays are regulated by the French Labour Law. The anaesthesiologist often works in a team with a nurse anaesthetist. The number of certified anesthesiologists in France is larger than that in Japan. Management of anesthesia in France seems to have an advantage in manpower.

[Nurse anesthetist in France].

We present the system of nurse anesthetist (Infirmier Anesthésiste Diplômé d'Etat: IADE) in France to the community of Japanese anesthesiologists. This French system with 70 years' history is older than the Japan Society of Anesthesiologists itself. There are 7000 nurse anesthetists in France now and the number of nurse anesthetists increases by 450-500 each year. Training to become a nurse anesthetist requires at least two years' experience as a general nurse and the general nurse must pass an examination after two years' special training in an anesthetistic nurse school to acquire the national certification. The nurse anesthetist's profession is regulated by French law. They work in a team with certified anesthesiologists. They can perform many kinds of anesthetic tasks including tracheal intubation and insertion of arterial catheter under the responsibility and supervision of certified anesthesiologists. The nurse anesthetists are not allowed to perform spinal, epidural, conduction and local anesthesia, although they can maintain these anesthesia and control these methods, e.g., by injecting local anesthetic agents through epidural catheter, following a specified prescription. The nurse anesthetists are not allowed to insert central venous and pulmonary artery catheters, although they can manage them. They are allowed to administer inhalation anesthetic agents, and inject venous anesthetic agents, muscle relaxants, their antagonists, and opioids by their own initiatives, but the decision for the use of catecholamine and emergency drugs is reserved to certified anesthesiologists. The nurse anesthetists perform other tasks preparing and checking anesthetic agents and equipment such as anesthetic machine, monitor, and defibrillator everyday, and sometimes use autologous blood recovery systems. The relationship between the certified anesthesiologist and the nurse anesthetist is marked by mutual respect, confidence and cooperation at each step of the anesthetic management, from induction to recovery of anesthesia. We believe that it is very safe for the patients to undergo anesthesia performed by nurse anesthetists under the control of certified anesthesiologists. We suggest that the introduction of the system equivalent to the French concept and improved training of nurse anesthetists can be the solution to overcome our current shortage of certified anesthesiologists in Japan.

Severe traumatic head injury in adults: which patients are at risk of early hyperthermia?

OBJECTIVE: Prevention of secondary insults, such as hyperthermia, is a major goal after traumatic brain injury. The aim of our study was to identify risk factors for early hyperthermia in severe head-injured patients. DESIGN: Retrospective cohort study. SETTING: A 17-bed multidisciplinary ICU of a 700-bed teaching hospital. PATIENTS: A total of 101 adult patients admitted from January 1999 to December 2001 requiring continuous monitoring of intracranial pressure according to international guidelines. MEASUREMENT AND RESULTS: Forty-four patients experienced early hyperthermia (at least one episode of body temperature >38.5 degrees C within the first 2 days). On univariate analysis five variables were associated with early hyperthermia: sex; body temperature; white blood cell count on admission; prophylactic use of acetaminophen; and diabetes insipidus within 2 days. On multivariate analysis, white blood cell count >14.5 x 10(9)/l on admission (odds ratio, 7.1; 95% confidence interval, 2.4-20.5; p=0.001) and a body temperature on admission >36 degrees C (odds ratio, 6.7; 95% confidence interval, 2.3-20.1) were strong risk factors of early hyperthermia. Prophylactic use of acetaminophen was negatively associated with early hyperthermia (odds ratio, 0.1; 95% confidence interval, 0.02-0.4). Patients who experienced early hyperthermia were less prone to have good recovery (GOS=5; p=0.03). More patients with severe or moderate disability (GOS=3 or 4) experienced early hyperthermia ( p=0.01). CONCLUSION: We identified a subgroup of patients at high risk of early hyperthermia, which is common in severe head-injured patients. These results could have clinical implications for prevention of hyperthermia after traumatic brain injury in adults.

Frequency and clinical impact of preserved bispectral index activity during deep sedation in mechanically ventilated ICU patients.

OBJECTIVE: Despite an overall correlation between the bispectral index of the EEG (BIS) and clinical sedation assessment, unexpectedly high BIS values can be observed at deep sedation levels. We assessed the frequency, interindividual variability and clinical impact of high BIS values during clinically deep sedation. DESIGN AND SETTING: Prospective observational study in two university-affiliated intensive care units. PATIENTS: Sixty-two mechanically ventilated patients requiring intravenous sedation and analgesia for >or=24 h. MEASUREMENTS AND MAIN RESULTS: Paired measurements of BIS and sedation measured on the adaptation to intensive care environment (ATICE) score were obtained every 3 h until awakening. A paired measurement with BIS >60 at deep sedation (ATICE Awakeness

QT interval measurement: evaluation of automatic QTc measurement and new simple method to calculate and interpret corrected QT interval.

BACKGROUND: Assessment of repolarization duration is often recommended to avoid administration of QT-prolonging drugs in patients with prolonged QTc interval, a frequent situation in the postoperative period. Bazett QT correction inappropriately increases QTc when heart rate is increased, and the use of the Fridericia formula may avoid a falsely prolonged QTc interval. The authors assessed automatic QT interval measurement to detect prolonged QTc interval (women >450 ms; men >440 ms) in the postoperative setting. METHODS: Automatic and manual electrocardiograms were performed in 108 patients after anesthesia. Automatic electrocardiographic measurement used the Bazett formula. Manual measurements were made from each electrocardiogram and used as the reference. Agreement between the two methods was analyzed. Bazett and Fridericia QT corrections were compared in this population. RESULTS: Agreement between automatic and manual measurements was low. The Fridericia correction, but not the Bazett correction, was independent from heart rate and allowed adequate QT correction. Sensitivity of automatic measurements to detect prolonged QTc-Bazett interval was 54%. Automatic QTc-Bazett interval less than 430 ms ruled out a manual prolonged QTc interval. When automatic QTc-Bazett was greater than 430 ms, this value was converted according to Fridericia. Automatic QTc-Fridericia greater than 430 ms identified all patients with prolonged manual QTc with a negative predictive error of 0% (95% confidence interval, 0-7%). QTc-Fridericia can be approximated by respectively adding or subtracting 5% to the uncorrected QT for each increase or decrease by 10 beats/min in heart rate from 60 beats/min. CONCLUSIONS: Automatic QTc-Bazett measurement, if abnormal, associated with calculation of QTc-Fridericia reliably identifies patients in whom manual QTc measurement must be performed to confirm postoperative prolonged QTc interval.