Vernaz S, Casanova L, Blanc F
… +3 more, Lebel S, Ughetto F, Paut O
Ann Fr Anesth Reanim
· 2014 Jun · PMID 24907188
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Since 2005, forgoing live-support (FLS) is allowed by the French law (known as the Leonetti law) for end-of-life patients only. This study aims at describing the variations over time in the use of the following methods t...Since 2005, forgoing live-support (FLS) is allowed by the French law (known as the Leonetti law) for end-of-life patients only. This study aims at describing the variations over time in the use of the following methods to end life: FLS, brain death and cardiopulmonary resuscitation failure (CPR failure). It is a single retrospective study from 2007 to 2012. The Cochran-Armitage trend test is used in the statistical analysis. Over six years, 263 of the 5100 children who were hospitalized in our intensive care unit died, which represents a 5.2% mortality rate. FLS increased yearly from 31% of the deaths in 2007, to 71% in 2012 (P=0.0008). The rate of CPR failure decreased over the same period (P=0.0015). The rate of brain death remained constant. Following to the Leonetti law, FLS increase, and palliative cares develop without any increase of mortality.
Leclercq T, Parrel S, Mierdl S
… +2 more, Cottin Y, Girard C
Ann Fr Anesth Reanim
· 2014 Jun · PMID 24880555
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A 30-year-old woman, with no medical history, is operated on for breast implants. In recovery room, an episode of torsade de pointes occurs, progressing to ventricular fibrillation. The ECG after cardiopulmonary resuscit...A 30-year-old woman, with no medical history, is operated on for breast implants. In recovery room, an episode of torsade de pointes occurs, progressing to ventricular fibrillation. The ECG after cardiopulmonary resuscitation and conversion to a normal sinus rhythm shows a corrected QT interval prolongation, whereas it is normalized after 48hours. We hypothesize that a ventricular fibrillation occurred after a torsade de pointes, due to drug-induced long QT syndrome during general anesthesia, with probably drug interaction.
Bordenave L, Moya-Plana A, Motamed C
… +1 more, Bourgain JL
Ann Fr Anesth Reanim
· 2014 Jun · PMID 24878060
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The repeated syncopes in case of head and neck cancer are a complication rarely described in the literature. They occur when the tumor invade the carotid sinus or the afferent fibers of the glossopharyngeal nerve. We rep...The repeated syncopes in case of head and neck cancer are a complication rarely described in the literature. They occur when the tumor invade the carotid sinus or the afferent fibers of the glossopharyngeal nerve. We report the case of a 62-year-old man presented episodes of syncope synchronous of a recurrent hypopharyngeal tumor scheduled for chemotherapy and gastrostomy. A computerized tomography showed a voluminous tumor expanded to the carotid and parapharyngeal spaces. After treatment by isporenaline chlorhydrate in intensive care unit, a pacemaker was implanted to prevent syncopes and allowed the beginning of the chemotherapy.
Alfonsi P, Slim K, Chauvin M
… +4 more, Mariani P, Faucheron JL, Fletcher D, le groupe de travail de la Société française d’anesthésie et réanimation (Sfar) et de la Société française de chirurgie digestive (SFCD)
Ann Fr Anesth Reanim
· 2014 May · PMID 24854967
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Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the fo...Early recovery after surgery provides patients with all means to counteract or minimize the deleterious effects of surgery. This concept is suitable for a surgical procedure (e.g., colorectal surgery) and comes in the form of a clinical pathway that covers three periods (pre-, intra- and postoperative). The purpose of this Expert panel guideline is firstly to assess the impact of each parameter usually included in the rehabilitation programs on 6 foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, water and energy imbalance, postoperative immobility, sleep alterations and postoperative complications; secondly, to validate the usefulness of each as criteria of efficiency criteria for success of rehabilitation programs. Two main criteria were selected to evaluate the impact of each parameter: the length of stay and frequency of postoperative complications. Lack of information in the literature forced experts to assess some parameters with criteria (duration of postoperative ileus or quality of analgesia) that mainly surrogate a positive impact for the implementation of an early recovery program. After literature analysis, 19 parameters were identified as potentially interfering with at least one of the foreseeable consequences of colorectal surgery. GRADE® methodology was applied to determine a level of evidence and strength of recommendation. After synthesis of the work of experts using GRADE® method on 19 parameters, 35 recommendations were produced by the organizing committee. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. A consensus was reached among anesthesiologists and surgeons on a number of approaches that are likely not sufficiently applied for rehabilitation programs in colorectal surgery such as: preoperative intake of carbohydrates; intraoperative hemodynamic optimization; oral feeding resume before ha24; gum chewing after surgery; patient out of bed and walking at D1. The panel also clarified the value and place of such approaches such as: patient information; preoperative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic prevention of nausea and vomiting; morphine-sparing analgesic techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of approaches such as: bowel preparation for colon surgery; maintain of the nasogastric tube; surgical drainage for colonic surgery.
Gagnoud R, Woillard JB, Ponsonnard S
… +3 more, Cros J, Youssef B, Nathan N
Ann Fr Anesth Reanim
· 2014 May · PMID 24845409
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OBJECTIVES: To describe the current use of epidural anesthesia (EA) apart from obstetrics, and to explain the reasons of its low utilization. STUDY DESIGN: Observational study. METHODS: A survey of practice with a self-q...OBJECTIVES: To describe the current use of epidural anesthesia (EA) apart from obstetrics, and to explain the reasons of its low utilization. STUDY DESIGN: Observational study. METHODS: A survey of practice with a self-questionnaire was sent by e-mail and available on Internet. Answers were compared between groups doing or not an epidural analgesia with exact Fisher tests (P<0.05 statistically significant). RESULTS: Among the 176 anesthesiologists who answered to the questionnaire, only 21.4% never used epidural analgesia. The main reasons were alternatives therapeutics such as PCA with opioids or TAP block (24/38 vs. 46/140). TAP block was the most common alternative used by more than 50% of anesthesiologists. Loss of competence (4/30 vs. 0/39) was rarely the reason to its low utilization. The low accessibility to specialized postoperative units was recognized in both groups as a limiting factor to do an epidural but not the fear of neurological complications. Those who never perform epidural analgesia were statistically more often physicians between 40 and 50 years (12/38 vs. 19/140). Heparin, aspirin and clopidogrel are no longer contraindications according to anesthesiologists less than 40 years old (50/68 vs. 31/68; 44/68 vs. 31/68; 37/68 vs. 23/68 respectively) but not for older. CONCLUSIONS: Epidural analgesia is performed more often by younger anesthesiologists. This survey suggests the need of specific postoperative area to allow anesthesiologist to perform and supervise safely this technique. Recommendations of the French society of Anesthesiologists are also poorly applied.
Biedermann S, Wodey E, De La Brière F
… +2 more, Pouvreau A, Ecoffey C
Ann Fr Anesth Reanim
· 2014 May · PMID 24836357
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BACKGROUND: In adults, the Post-Anesthetic Discharge Scoring System (PADSS) was built to secure the discharge after outpatient surgery. We evaluate a pediatric adaptation: the Pediatric-PADSS (Ped-PADSS). STUDY DESIGN: P...BACKGROUND: In adults, the Post-Anesthetic Discharge Scoring System (PADSS) was built to secure the discharge after outpatient surgery. We evaluate a pediatric adaptation: the Pediatric-PADSS (Ped-PADSS). STUDY DESIGN: Prospective cohort. METHODS: This was a prospective, observational, monocentric study for ambulatory patients. Ped-PADSS is built on 5 items each quoted 0, 1, or 2: hemodynamics, state of awakening, nausea/vomiting, pain and bleeding. A result ≥9/10 validated discharge if the anesthetist did not wish to review the patient, if the parents did not wish to revisit the anesthetist or if there was no hoarseness or dyspnea. The discharge was validated by the anesthetist and the surgeon. Ped-PADSS was made without the knowledge of the nursing team, one hour after return in service and repeated hourly. Addition of patient demographic data, the collection included the hours of leave by the anesthetist, surgeon and Ped-PADSS, the duration of hospital stay post procedure. RESULTS: On 150 patients, 148 patients were allowed to go out with the Ped-PADSS, one patient was released despite a Ped-PADSS<9. One patient was hospitalized for a surgical bleeding in agreement with the anesthetist, surgeon and the Ped-PADSS. Ninety-five percent of patients had a Ped-PADSS ≥9 after 2hours monitoring in the ambulatory unit. CONCLUSION: The majority of the children have met the criteria for discharge at the end of 2hours postoperative monitoring. The use of this score could reduce the hospitalization time in ambulatory unit.
Ann Fr Anesth Reanim
· 2014 May · PMID 24836116
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OBJECTIVE: To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area. METHODS: A declarative survey was conducted from November 2011 to January 2012 with an online questionnai...OBJECTIVE: To assess the management of postpartum hemorrhage (PPH) by anaesthesiologists in Pays de la Loire area. METHODS: A declarative survey was conducted from November 2011 to January 2012 with an online questionnaire to assess prevention and PPH specific care and to clarify the PPH transfusion practices and interest of new therapies. Nine indicators of adherence to clinical practice guidelines were selected to distinguish two groups: one group "adhering to the RCP" and another "not adhering to the RCP". RESULTS: Response rate 53%. One hundred and one responses were analyzed. Use of a collection bag graded blood receipt pockets 93%, start time of PPH noted: 76%, leaf specific monitoring: 67%, management of the third part of the work: 78%. The evacuation of the placenta is performed within 30minutes in 75% of cases. The transfusion strategy happens early (92% before the biological assessment results) and "aggressive" (ratio RCB/FFP is 1/1 for 72%). The use of tranexamic acid is not systematic (53%). Seventy-nine percent of respondents adhere to the RCP. Practitioners in maternity level 1 (with few deliveries) don't follow these RCP as much. CONCLUSION: Some inappropriate practices remain in structures not used to support them. The use of new therapies remain controversial. The priority at this time is the implementation and enforcement of the current RCP, not their modifications.
Blasco V, Antonini F, Zieleskiewicz L
… +4 more, Hammad E, Albanèse J, Martin C, Leone M
Ann Fr Anesth Reanim
· 2014 May · PMID 24835538
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BACKGROUND: At the bedside, the reference method for creatinine clearance determination is based on the measurement of creatinine concentrations in urine and serum (mCrCl). Several models are available to calculate the c...BACKGROUND: At the bedside, the reference method for creatinine clearance determination is based on the measurement of creatinine concentrations in urine and serum (mCrCl). Several models are available to calculate the creatinine clearance from the serum creatinine concentration. This observational survey aimed at testing the hypothesis that the proposed equations are unreliable to determine accurate creatinine clearance in patients admitted to intensive care unit (ICU). METHOD: Creatinine clearance was determined by the use of mCrCl. Then, we compared three equations: Cockcroft-Gault (CG), Simplified Modification of Diet in Renal Disease (MDRDs), and Chronic Kidney Disease Epidemiology (CKD-EPI) in 156 consecutive patients within the first 24hours after ICU admission. We tested the hypothesis that the three equations were equivalent. The agreement between the three equations was evaluated by linear regression and Bland and Altman analysis. RESULTS: Bland and Altman analysis showed similar agreement between the three equations. The biases and precisions were -4.8±51, -1.3±50, and 8.2±44 for CG, MDRDs, and CKD-EPI equations, respectively (P>0.05). The precisions were similar for the three equations (P>0.05). The percentages of outliers at ±30% were 44%, 45%, and 49% for CG, MDRDs, and CKD-EPI, respectively (P>0.05). CONCLUSION: Regarding the high percentage of outliers, the use of these equations cannot be recommended in ICU patients.
Vardon F, Harrois A, Duranteau J
… +1 more, Geeraerts T
Ann Fr Anesth Reanim
· 2014 May · PMID 24833399
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Pelvic trauma care is complex since it is frequently associated with multiple injuries and may lead to dramatic and uncontrollable haemorrhage. After pelvic trauma, the mortality, around 8 to 10%, is mainly related to se...Pelvic trauma care is complex since it is frequently associated with multiple injuries and may lead to dramatic and uncontrollable haemorrhage. After pelvic trauma, the mortality, around 8 to 10%, is mainly related to severe pelvic hemorrhage but also to extrapelvic injuries (thoracic, abdominal or brain injuries). It is therefore crucial to manage pelvic trauma in specialized trauma center. The initial trauma assessment aims to determine the role of the pelvic injury in hemorrhage to define the therapeutic strategy of pelvic trauma care (arterial embolisation/pelvic ring stabilisation). This review was performed with a systematic review of the literature; it describes the pelvic fracture pathophysiology, and the efficacy and safety of haemostatic procedures and with their respective indications. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture.
Nouri M, Barré P, Vesvard D
… +2 more, Hanifi M, Estèbe JP
Ann Fr Anesth Reanim
· 2014 May · PMID 24821343
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OBJECTIVE: Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoul...OBJECTIVE: Evaluation of treatment of shoulder-hand syndromes resistant to conventional therapeutic. This approach consists of an intensive treatment based on arthrographic distension with rapid mobilization of the shoulder under general anaesthesia and on active rehabilitation under regional analgesia using infraclavicular brachial plexus catheter. MATERIAL AND METHODS: It was a retrospective study of twenty-five consecutive patients with severe shoulder-hand syndrome treated between 2007 and 2012. Besides their persistent pain, these patients presented a functional disability of their shoulder, wrist and hand. Treatment was initiated at least three months after diagnosis. All were assessed at the admission and six months later. RESULTS: After treatment, pain was reduced by at least three points at the NS in 64% of the patients. Twelve patients described a complete recovery of their shoulder function; eleven patients described a normal hand function recovery and six patients a partial recovery allowing regular life. Nineteen patients evaluated their functional improvement of more than 50%. Only two patients with more than one year of chronic pain reported no improvement after treatment. CONCLUSION: After failure of the physiotherapy and analgesic treatment, there are no clear consensual procedures and guidelines remains discussed. The current study combined different approaches with a significant improvement of this complex regional pain syndrome called shoulder-hand syndromes.
Bazin JE, Attias A, Baghdadi H
… +17 more, Baumann A, Bizouarn P, Claudot F, Eon B, Fieux F, Frot C, Guibet Lafaye C, Muzard O, Nicolas-Robin A, Orjubin V, Otero-Lopez M, Pelluchon C, Pereira J, Roussin F, Vigué B, Beydon L, Membres du Comité éthique de la Société française d’anesthésie et de réanimation (ICARE)
Ann Fr Anesth Reanim
· 2014 May · PMID 24821342
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In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. Th...In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. They are a source of medical errors and contribute to burn-out. Patients can become the victims of such conflicts, which deserve ethical reflection. Their resolution through analysis and shared solutions is necessary. This article seeks to analyse these conflicts, taking into account their specificities and constraints. In order to understand this context, it is important to consider the specificities of each group involved and the records of such situations. Several factors can prevent these conflicts, first and foremost the patients themselves and the quality of the care that is provided. Medical deontology aims mainly at preventing and resolving these conflicts. Generally speaking, the quality approach which is increasingly applied in health care institutions (involving declarations of adverse events, morbidity/mortality reviews, benchmarking, analysis and improvement of practices, etc.) also contributes to the prevention and resolution of disagreements. The teaching of communication techniques that begins with the initial training, the evaluation of team behaviours (through simulation training for example), the respect of others' constraints, particularly when it comes to learning, as well as transparency regarding conflicts of interests, are all additional elements of conflict prevention. Lastly, conflicts may at times be caused by deviant behaviours, which must be met with a clear and uncompromising collective and institutional approach. This article concludes by offering a standardised approach for conflict resolution.
Burnod A, Choquet C, Houissa H
… +3 more, Danis J, Pellenc Q, Duchateau FX
Ann Fr Anesth Reanim
· 2014 May · PMID 24821341
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Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in acc...Advanced care decision in emergency medicine is difficult for the elderly. How to be fair, avoiding an unreasonable obstinacy? Based on the case of very old person, we show how an optimal management can be decided in accordance with the spirit of the law.
Artus M, Laviolle B, Maurice A
… +2 more, Malledant Y, Beloeil H
Ann Fr Anesth Reanim
· 2014 May · PMID 24821340
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OBJECTIVE: Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to iden...OBJECTIVE: Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to identify risk factors following urology surgery. DESIGN: Retrospective observational study. PATIENTS: Two hundred and twenty-eight patients scheduled for urology surgery. Reasons for non-inclusions: patients who underwent a procedure not defined as being associated with PPSP. METHODS: Surgical urologic procedures potentially associated with PPSP were defined. All patients who had one of these procedures during the study period received a questionnaire by mail at least 3 months after the surgery. The files of these patients were retrospectively studied. RESULTS: Eight percent of the patients had preoperative pain. PPSP, assessed approximately 6 months after the surgery, was reported by 24% of the patients. Twenty-five (36%) of them reported neuropathic pain. Patients with PPSP had significantly more preoperative pain and an increased postoperative morphine consumption. Postoperative NSAID administration led to less persistent pain. Multivariate logistic regression analysis identified two independent risk factors of developing persistent pain: preoperative pain (OR=21.6, 95% CI 6.7-69.5, P<0.0001), morphine consumption 48 hours after surgery higher than 6mg (OR=2.3, 95% CI 1.2-4.3, P=0.0118). CONCLUSION: These findings confirm the role of preoperative pain and morphine consumption in the genesis of PPSP and call for establishing clinical perioperative pathways tailored to the patient.
Gobin J, Lonjaret L, Pailhas A
… +2 more, Bayoumeu F, Minville V
Ann Fr Anesth Reanim
· 2014 May · PMID 24821339
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Accidental dural puncture (ADP) is a common complication of epidural catheter insertion, and may lead to post-dural puncture headache (PDPH), especially in obstetric patients. Epidural blood patch (BP) is the most effect...Accidental dural puncture (ADP) is a common complication of epidural catheter insertion, and may lead to post-dural puncture headache (PDPH), especially in obstetric patients. Epidural blood patch (BP) is the most effective treatment of PDPH. Prophylactic BP has shown its efficacy to prevent PDPH; nevertheless, this method may be insufficient. We report an ADP case before induction of labor in a 28-year-old parturient. To avoid PDPH, an intrathecal catheter was immediately inserted after ADP and an epidural catheter was also inserted at the interspace above. Catheters were kept in place for more than 24hours. A prophylactic BP was performed immediately after removal of the intrathecal catheter. The patient did not experience any headache. This combination of treatments (intrathecal catheter insertion+prophylactic BP) may be a good alternative approach to prevent PDPH, even if it has to be warranted by other clinical studies.
Duwat A, Petiot S, Malaquin S
… +2 more, Hinard S, Dupont H
Ann Fr Anesth Reanim
· 2014 May · PMID 24821338
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The two current cases reported present the situation of "can't intubate can't ventilate" patients with life-saving cricothyrotomy before surgical tracheotomy. These situations emphasize the necessity for clinicians to ma...The two current cases reported present the situation of "can't intubate can't ventilate" patients with life-saving cricothyrotomy before surgical tracheotomy. These situations emphasize the necessity for clinicians to master difficult intubation and oxygenation algorithms and all available alternative techniques.