Gouraud D, Dumont R, Asehnoune K
… +1 more, Lejus C
Ann Fr Anesth Reanim
· 2014 Jan · PMID 24378050
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OBJECTIVES: While coat contamination increases progressively with the duration of use, there are no guidelines on how frequently medical white coats should be changed. The purpose of our study was to examine the turnover...OBJECTIVES: While coat contamination increases progressively with the duration of use, there are no guidelines on how frequently medical white coats should be changed. The purpose of our study was to examine the turnover of individual batch of medical white coats in a university hospital. STUDY DESIGN AND METHODS: A retrospective analysis of the white coat turnover of 826 physicians was performed by using the hospital laundry computerized database and an electronic declarative survey (240 responses) to evaluate the duration of medical white coat use. RESULTS: There was a wide discrepancy between the data extracted from the laundry database and those from the survey. The median factual duration of use (20 days, range: 15-30) corresponding to a turnover of 2 (1-2) coats per month, was widely underestimated by the physicians. Multivariate analysis identified 4 independent factors associated with a declared use of coats longer than 7 days: estimation of insufficient gown turnover (OR 14.8 [4.8-45.8]), daily change considered as not useful (OR 5.1 [2.4-10.8]), non-medical specialty (OR 2.95 [1.5-5.6]) and presence of stains on gowns (2.9 [1.5-5.5]). CONCLUSION: Shortening white coat use should be included in medical education in order to improve the good practice rules of hospital hygiene.
Castel-Lacanal E, Tarri M, Loubinoux I
… +4 more, Gasq D, de Boissezon X, Marque P, Simonetta-Moreau M
Ann Fr Anesth Reanim
· 2014 Feb · PMID 24378049
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OBJECTIVES: Transcranial magnetic stimulations (TMS) have been used for many years as a diagnostic tool to explore changes in cortical excitability, and more recently as a tool for therapeutic neuromodulation. We are int...OBJECTIVES: Transcranial magnetic stimulations (TMS) have been used for many years as a diagnostic tool to explore changes in cortical excitability, and more recently as a tool for therapeutic neuromodulation. We are interested in their applications following brain injury: stroke, traumatic and anoxic brain injury. DATA SYNTHESIS: Following brain injury, there is decreased cortical excitability and changes in interhemispheric interactions depending on the type, the severity, and the time-lapse between the injury and the treatment implemented. rTMS (repetitive TMS) is a therapeutic neuromodulation tool which restores the interhemispheric interactions following stroke by inhibiting the healthy cortex with frequencies ≤1Hz, or by exciting the lesioned cortex with frequencies between 3 and 50Hz. Results in motor recovery are promising and those in improving aphasia or visuospatial neglect are also encouraging. Finally, the use of TMS is mainly limited by the risk of seizure, and is therefore contraindicated for many patients. CONCLUSION: TMS is a useful non-invasive brain stimulation tool to diagnose the effects of brain injury, to study the mechanisms of recovery and a non-invasive neuromodulation promising tool to influence the post-lesional recovery.
Bachellerie B, Ruiz S, Conil JM
… +4 more, Crognier L, Seguin T, Georges B, Fourcade O
Ann Fr Anesth Reanim
· 2014 Jan · PMID 24378048
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Dabigatran is a direct thrombin inhibitor indicated for stroke and systemic embolism prevention in patients with non-valvular atrial fibrillation. No reversal agent exists, but hemodialysis has been proposed as dabigatra...Dabigatran is a direct thrombin inhibitor indicated for stroke and systemic embolism prevention in patients with non-valvular atrial fibrillation. No reversal agent exists, but hemodialysis has been proposed as dabigatran removal method. We report a case of an 80-year-old man presenting hemorrhage with dabigatran overdose caused by obstructive acute renal failure. Before nephrostomy, several hemodialysis sessions were necessary to remove dabigatran probably because of its large volume of distribution.
Ann Fr Anesth Reanim
· 2014 Jan · PMID 24378045
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Interpreting a Bispectral Index (BIS) of "0", corresponding to an isolelectric electroencephalography, can be difficult. After ruling out technical issues, such as leads disconnection, several possible causes for a decre...Interpreting a Bispectral Index (BIS) of "0", corresponding to an isolelectric electroencephalography, can be difficult. After ruling out technical issues, such as leads disconnection, several possible causes for a decrease in the BIS persists, including deep anesthesia, hypothermia, decrease in the cerebral perfusion pressure and cerebral ischemia. We report a sudden transient decrease of the BIS to "0" in a patient that underwent a coil embolization of a ruptured intracranial aneurysm and suggest that the change in BIS values could provide useful information about the cerebral hemodynamic during aneurysm treatment and might provide indications of a serious cerebral event.
Rinehart J, Le Manach Y, Douiri H
… +5 more, Lee C, Lilot M, Le K, Canales C, Cannesson M
Ann Fr Anesth Reanim
· 2014 Mar · PMID 24378044
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OBJECTIVE: Intraoperative haemodynamic optimization based on fluid management and stroke volume optimization (Goal Directed Fluid Therapy [GDFT]) can improve patients' postoperative outcome. We have described a closed-lo...OBJECTIVE: Intraoperative haemodynamic optimization based on fluid management and stroke volume optimization (Goal Directed Fluid Therapy [GDFT]) can improve patients' postoperative outcome. We have described a closed-loop fluid management system based on stroke volume variation and stroke volume monitoring. The goal of this system is to apply GDFT protocols automatically. After conducting simulation, engineering, and animal studies the present report describes the first use of this system in the clinical setting. STUDY DESIGN: Prospective pilot study. PATIENTS: Patients undergoing major surgery. METHODS: Twelve patients at two institutions had intraoperative GDFT delivered by closed-loop controller under the direction of an anaesthesiologist. Compliance with GDFT management was defined as acceptable when a patient spent more than 85% of the surgery time in a preload independent state (defined as stroke volume variation<13%), or when average cardiac index during the case was superior or equal to 2.5l/min/m(2). RESULTS: Closed-loop GDFT was completed in 12 patients. Median surgery time was 447 [309-483] min and blood loss was 200 [100-1000] ml. Average cardiac index was 3.2±0.8l/min/m(2) and on average patients spent 91% (76 to 100%) of the surgery time in a preload independent state. Twelve of 12 patients met the criteria for compliance with intraoperative GDFT management. CONCLUSION: Intraoperative GDFT delivered by closed-loop system under anaesthesiologist guidance allowed to obtain targeted objectives in 91% of surgery time. This approach may provide a way to ensure consistent high-quality delivery of fluid administration and compliance with perioperative goal directed therapy.
Lenfant F, Pean D, de Mesmay M
… +4 more, Maurice A, Decagny S, Lejus C, Langeron O
Ann Fr Anesth Reanim
· 2014 Jan · PMID 24373674
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GOAL OF THE STUDY: To evaluate a single-use fiberscope, the Ascope-Trainer, for the training in the intubation under fiberscope. TYPE OF STUDY: Prospective randomized study approved by the local ethic committee. METHODOL...GOAL OF THE STUDY: To evaluate a single-use fiberscope, the Ascope-Trainer, for the training in the intubation under fiberscope. TYPE OF STUDY: Prospective randomized study approved by the local ethic committee. METHODOLOGY: After evaluation of their level of expertise, "experienced" or "novices" in intubation under fiberscope, the doctors attending the Training for Referents in Difficult Airway Management performed a test on labyrinth with a standard fiberscope (T1). After they were assigned to two groups, training with the Ascope-Trainer (group A, n=35) or with a classic fiberscope (group C, n=29), they trained during 15 minutes and performed a new test (T2). An analysis of variance was used to compare means. A goal for the training was determined according to the "experienced" doctors' mean T1. A test of Khi(2) was used for the comparison of the number of participants having reached this goal as well as the progress in both groups A and C. RESULTS: The T1 in the "experienced" group was 76 ± 31 s and the training improved significantly T2 (53 ± 17 s). Considering the novices, T2 was significantly lower than T1 in the group A (77 ± 38 s versus 135 ± 68 s) as well as in C (64 ± 28 s versus 122 ± 60 s), and the proportion of the novices having reached the goal of training was comparable in both groups. CONCLUSIONS: Because its use is similar to the standard fiberscope, the Ascope-Trainer may be interesting for this type of training.
Ann Fr Anesth Reanim
· 2014 Jan · PMID 24373673
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OBJECTIVES: The aim of the study was to compare NIRS parameters in combination with a vascular occlusion test (VOT) at a proximal (leg) and a distal (foot) site in male and female. STUDY DESIGN: A prospective experimenta...OBJECTIVES: The aim of the study was to compare NIRS parameters in combination with a vascular occlusion test (VOT) at a proximal (leg) and a distal (foot) site in male and female. STUDY DESIGN: A prospective experimental study in healthy subjects. PATIENTS AND METHODS: Twenty volunteers (10 male, 10 female, 28 ± 4 years) were investigated during 4 experimental steps: baseline, ischemia, reperfusion, and baseline. For each volunteer, 3 NIRS optodes were placed on right and left calves and the left arch of the foot. Blood pressure, heart rate and peripheral pulse oxymetry were monitored. RESULTS: Significant differences were observed at baseline between regional oxygen saturation (rSO₂) values according to the site of measurement (proximal rSO₂ 81 ± 9% vs distal rSO₂ 60 ± 5%, P<0.001) but not according to gender. Both decreases in proximal and distal rSO₂ during ischemia and increases over baseline values during reperfusion depended on group membership (male or female). NIRS parameters during the VOT were significantly higher in male when compared with female at the proximal site: desaturation rate 5.6% (IQR: 5.5) vs 2.5% (IQR: 0.8), P=0.001; resaturation rate 40.7% (IQR: 6.6) vs 21.7% (IQR: 5.4), P=0.003; and ΔrSO₂ 10.0% (IQR: 7.0) vs 5.5% (IQR: 6.0), P=0.041. CONCLUSIONS: Values of rSO₂ at the lower limb varied according to the anatomical site of measurement. A VOT induced major changes in rSO₂ that differed between male and female. These results should be taken into account in further clinical studies.
Ann Fr Anesth Reanim
· 2014 Feb · PMID 24368069
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How does general anesthesia (GA) work? Anesthetics are pharmacological agents that target specific central nervous system receptors. Once they bind to their brain receptors, anesthetics modulate remote brain areas and en...How does general anesthesia (GA) work? Anesthetics are pharmacological agents that target specific central nervous system receptors. Once they bind to their brain receptors, anesthetics modulate remote brain areas and end up interfering with global neuronal networks, leading to a controlled and reversible loss of consciousness. This remarkable manipulation of consciousness allows millions of people every year to undergo surgery safely most of the time. However, despite all the progress that has been made, we still lack a clear and comprehensive insight into the specific neurophysiological mechanisms of GA, from the molecular level to the global brain propagation. During the last decade, the exponential progress in neuroscience and neuro-imaging led to a significant step in the understanding of the neural correlates of consciousness, with direct consequences for clinical anesthesia. Far from shutting down all brain activity, anesthetics lead to a shift in the brain state to a distinct, highly specific and complex state, which is being increasingly characterized by modern neuro-imaging techniques. There are several clinical consequences and challenges that are arising from the current efforts to dissect GA mechanisms: the improvement of anesthetic depth monitoring, the characterization and avoidance of intra-operative awareness and post-anesthesia cognitive disorders, and the development of future generations of anesthetics.
Reynaud Q, Catella J, Diconne E
… +2 more, Lafond P, Tardy B
Ann Fr Anesth Reanim
· 2014 Jan · PMID 24365154
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Lower limbs superficial venous thrombosis (LLSVT) is usually considered as common and of a benign prognosis. LLSVT can, however, be responsible for major thromboembolic complications: lower limbs deep vein thrombosis (LL...Lower limbs superficial venous thrombosis (LLSVT) is usually considered as common and of a benign prognosis. LLSVT can, however, be responsible for major thromboembolic complications: lower limbs deep vein thrombosis (LLDVT) and pulmonary embolism (PE). We report a case of a LLSVT complicated with a massive bilateral PE and an ischemic cerebral stroke, occurring immediately after a varicose vein surgery. Venous ultrasonography of the lower limbs must be systematically performed in case of LLSVT, in order to evaluate the presence of an associated LLDVT. A rigorous diagnostic and therapeutic approach is the only way to optimize the treatment of this disorder, and to avoid the occurrence of dramatic venous thromboembolic complications.
Ann Fr Anesth Reanim
· 2014 Feb · PMID 24365153
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Deciding to cease treatment in intensive care unit patients whose prognosis is hopeless allows programming the moment of death, and hence, post mortem transplantable organ donation. Such organ donations are more frequent...Deciding to cease treatment in intensive care unit patients whose prognosis is hopeless allows programming the moment of death, and hence, post mortem transplantable organ donation. Such organ donations are more frequent in Anglo-Saxon countries. In the context of growing organ needs, they have significantly increased the number of organs that are available for transplant. Progressive experience has shown that crystal-clear procedures must be set up in order to avoid lack of understanding, opposition, or even conflict between involved medical teams and immediate relatives of potential donors. The decision of organ transplantation must totally be separated from the decision of treatment cessation. Supportive treatment cessation must be done according to previously established procedures. Medications that are compatible with organ transplantation must be listed. Finally, the needs of patient relatives must be met.
Ann Fr Anesth Reanim
· 2014 Feb · PMID 24365152
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For the last 20 years or so, conflicts on life-support have become the object of widespread media coverage. By focusing public opinion on the alleged physicians' unreasonable obstinacy, these publicized cases impact soci...For the last 20 years or so, conflicts on life-support have become the object of widespread media coverage. By focusing public opinion on the alleged physicians' unreasonable obstinacy, these publicized cases impact social debates on life-support. By these, they justify claims for the legalization of assisted suicide, specifically the practice of termination of life by lethal injection. Via a conducted survey of the various caretakers and families involved in this type of situation, we propose an analysis based on the different forms of unreasonable obstinacy. The reasonable or unreasonable nature of treatments can often be perceived differently by physicians, caretakers and families. At least 6 unreasonable obstinacy cases can be brought to light. Publicized cases always involve a conflict between the physicians in charge and the families who view the situation as unreasonable. Nonetheless, evidence shows that in these situations, the roles are often reversed, and the families are the ones demanding the use of unreasonable care. A typical example of this is a recent case that became the object of legal proceedings in France. As it turns out, the publicized filter does not reflect the true reality of cases involving unreasonable care. Specific procedures could aid in notifying the existence of such situations. The role of health care professionals (excluding physicians) appears to play an essential part in preventing these situations from happening.
Ann Fr Anesth Reanim
· 2014 Feb · PMID 24361283
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Six clinical studies of chronic electrical modulation of deep brain circuits published between 1968 and 2010 have reported effects in 55 vegetative or minimally conscious patients. The rationale stimulation was to activa...Six clinical studies of chronic electrical modulation of deep brain circuits published between 1968 and 2010 have reported effects in 55 vegetative or minimally conscious patients. The rationale stimulation was to activate the cortex through the reticular-thalamic complex, comprising the tegmental ascending reticular activating system and its thalamic targets. The most frequent intended target was the central intralaminar zone and adjacent nuclei. Hassler et al. also proposed to modulate the pallidum as part of the arousal and wakefulness system. Stimulation frequency varied from 8Hz to 250Hz. Most patients improved, although in a limited way. Schiff et al. found correlations between central thalamus stimulation and arousal and conscious behaviours. Other treatments that have offered some clinical benefit include drugs, repetitive magnetic transcranial stimulation, median nerve stimulation, stimulation of dorsal column of the upper cervical spinal cord, and stimulation of the fronto-parietal cortex. No one treatment has emerged as a gold standard for practice, which is why clinical trials are still on-going. Further clinical studies are needed to decipher the altered dynamics of neuronal network circuits in patients suffering from severe disorders of consciousness as a step towards novel therapeutic strategies.
Ann Fr Anesth Reanim
· 2014 Feb · PMID 24361282
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When a severe traumatic brain-injured patient arrives to hospital, fear of failure and definite opinions about the outcome modify early care and provoke self-fulfilling prophecies. It is obvious that working on prognosis...When a severe traumatic brain-injured patient arrives to hospital, fear of failure and definite opinions about the outcome modify early care and provoke self-fulfilling prophecies. It is obvious that working on prognosis is not only useful to inform relatives but also permits to maintain a high level of care, key for a better outcome. Mortality is high (40-50%) if deaths in the first days are not excluded. Following guidelines in all cases will permit to decrease the number of preventable death and a decrease in morbidity. Well-defined networks of care leading to specialized centres with multimodal monitoring give best results. However, only 20% of living patients return to their previous life with mild handicap. These unsatisfactory results require intensifying research, notably in early rehabilitation in intensive care unit. Ethic issues should be discussed after few days of care and dialogue with relatives in a defined "window of opportunity". Ideally, we need to find strong and early indicators of outcome to limit fears on presumed handicap. A magnetic resonance imaging (MRI) sequence called diffusion tensor imaging (TDI) permits to visualise traumatic axonal injury. Studies with complex statistical methodology give a good estimated probability of bad outcome but must be confirmed by more validation studies. Progress will come from a better understanding of physiopathology. Focuses on processing chain, rapid multi-monitoring, biomarkers, and investigations in MRI and TDI will help to establish opportunities for treatments and to determine limits.