The number of patients with cardiac pacemaker is continuously increasing. The anesthetic management of these patients is often trivialized, particularly during minor surgery. However there is always a potential risk of d...The number of patients with cardiac pacemaker is continuously increasing. The anesthetic management of these patients is often trivialized, particularly during minor surgery. However there is always a potential risk of dysfunction during anesthesia. Perioperative management of these patients must be careful and standardized to avoid accidents. We report a case of cardiac arrest during general anesthesia for a day-surgery secondary to pacemaker dysfunction by increasing pacing thresholds in a young adult patient. Rapid onset after induction, without any surgical stimulation, has raised the question of the involvement of anesthetic drugs like propofol.
The assessment of the risk of pulmonary aspiration of gastric contents may be difficult in the preoperative period, apart from typical circumstances. The development of ultrasonography in anesthesia and critical care has...The assessment of the risk of pulmonary aspiration of gastric contents may be difficult in the preoperative period, apart from typical circumstances. The development of ultrasonography in anesthesia and critical care has led to consider ultrasonic imaging of gastric contents for preoperative risk assessment of "full" stomach in clinical practice. Ultrasonography of the body of the stomach allows direct visualization of the gastric contents. However, the stomach is often difficult to identify, particularly when it is empty. Moreover, quantitative assessment of gastric volume is delicate, and no standardized method of ultrasonography of the body of the stomach for preoperative assessment of gastric contents was described. On the contrary, ultrasonography of the antral cross-sectional area, which was initially described for the assessment of gastric emptying as an alternative method to repeated measurements of the variations of antropyloric volume after ingestion of a test meal, is easy to perform and is highly reproducible through using the aorta and the left lobe of the liver as internal landmarks. Qualitative assessment of the gastric antrum allows easily diagnosis of a "full" stomach. The measurement of antral area may allow a more accurate estimate of the presence or absence of gastric contents at risk of lung injury in the event of regurgitation and aspiration (gastric volume >0.8 ml/kg and/or with solid particles), defining the "risk" stomach. The use of antral ultrasonography may help the anesthesiologist to assess the risk of pulmonary aspiration according to clinical history of the patient, in order to choose an appropriate strategy minimizing the occurrence of this complication.
OBJECTIVES: To evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and p...OBJECTIVES: To evaluate theoretical and practical knowledges of intraosseous (IO) access in adults patients in France in 2012. STUDY DESIGN: National observational descriptive transversal study as survey of opinion and practices. MATERIALS AND METHODS: An email, with an URL to online computerized quiz, was sent to residents and medical doctors who were working, in France, in anesthesiologist units, intensive care units or emergency units. Several questions were asked about theoretical and practical knowledges concerning IO access. RESULTS: After 1359 responses, 396 (29%) practitioners have used an IO kit mainly in case of cardiopulmonary arrest in adults (68%). The insurance of operators in this technique and the rate of physicians who has even put an IO catheter increased with the years of experience of physicians. The reasons given for not using an IO access were no trouble placing a peripheral vein (77%) and unfamiliarity with the equipment and technology (32%). Most of practitioners (753 [55%]) have been trained and 90% (n=265) of untrained doctors believe that training was necessary. The powered system was the most used (71%). CONCLUSION: Only 29% of practitioners have ever used an IO kit. With the new IO kits, a theoretical and practical training is needed to ensure IO kit used.
OBJECTIVE: Percutaneous chest drainage guidelines were published in 2010 by the British Thoracic Society. On several points (insertion technique, drain size), they seem to differ from French practices. Our objectives wer...OBJECTIVE: Percutaneous chest drainage guidelines were published in 2010 by the British Thoracic Society. On several points (insertion technique, drain size), they seem to differ from French practices. Our objectives were to evaluate practice of pleural drainage in French University surgical intensive care units (ICU's), and to compare it with the British guidelines. STUDY DESIGN: National phone survey. METHODS: Physicians working in 58 ICU's were surveyed first in 2007, and subsequently in 2012. They were read a questionnaire to evaluate the demographic characteristics of their units, their indication for pleural drainage, how they quantified pleural effusion, and their technique for drain insertion. Data from the two surveys were compared to detect an evolution in practice following the publication of the British guidelines. Results are expressed as the mean response. RESULTS: In 2007, pleural drainage indications relied on various respiratory criteria in 91% of cases (versus 95% in 2012) and/or on pleural effusion volume in 71% of cases (versus 59% in 2012). Trocars (Monod or Joly) were used in 68% of the procedures in 2007. In the rest, either blunt dissection, a Pleurocath® or the Seldinger technique was utilized. From 2007 to 2012, the Seldinger technique increased in frequency (10% versus 22%, P=0.005) while Monod trocar usage decreased (41% vs 29%, P=0.012). Ultrasound before pleural effusion drainage became nearly systematic in 2012 (60% vs 86%, P<0.001). CONCLUSION: The frequent use of trocar (and therefore of large drains) for pleural drainage in French ICU's differs significantly from the British guidelines.
During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adr...During stress, the relationship between the central nervous system and the immune system is essential to maintain homeostasis. The main neuroendocrine system involved in this interaction is the hypothalamic-pituitary-adrenal axis (HPA), which via the synthesis of glucocorticoids will modulate the intensity of the inflammatory response. Anaesthetic agents could be interacting with the HPA axis during surgery. Although etomidate currently remains in the center of the discussions, it seems, at least experimentally, that most hypnotics have the capacity to modulate the synthesis of adrenal steroids. Nevertheless, with the large literature on this subject, etomidate seems to be the most deleterious hypnotic agent on the HPA axis function. Its use should be limited when HPA axis is already altered.
A round table, organized by the French Society of Perfusion (Sofraperf) at the French national congress on extracorporeal circulations (Perfusion 2013), was attended by perfusionists, anaesthesiologists, intensivists and...A round table, organized by the French Society of Perfusion (Sofraperf) at the French national congress on extracorporeal circulations (Perfusion 2013), was attended by perfusionists, anaesthesiologists, intensivists and surgeons around the theme of respiratory veno-venous support and veno-arterial circulatory support with extracorporeal oxygenation in intensive care units. The debate was conducted in a participatory manner by bi-directional questions-answers session between moderators and assistance. The authors report management of this type of therapy that is not perfectly homogeneous, supported on literature data. Cannulae, cannulation, circuit, oxygenator, anticoagulation, control, surveillance, weaning are subject to paragraphs with defined entry whose contents are mutually enriching.
Ethylene glycol poisoning is rare, but prompt diagnosis is crucial, in order to initiate specific treatments. Herein, we report the case of a patient who was admitted to ICU for coma and extreme metabolic acidosis with u...Ethylene glycol poisoning is rare, but prompt diagnosis is crucial, in order to initiate specific treatments. Herein, we report the case of a patient who was admitted to ICU for coma and extreme metabolic acidosis with unexpected hyperlactatemia on initial ICU blood gas analyzer. Ethylene glycol poisoning was diagnosed, and hyperlactatemia was ruled out on a blood sample sent to the biochemistry department. Interference of blood gas analyzers lactate electrodes with metabolites of ethylene glycol were the source of this apparent hyperlactatemia. Symptoms gradually improved and false hyperlactatemia resolved after renal replacement therapy and fomepizole administration. Time course of ethylene glycol concentration showed similar evolution. After initial confirmation of ethylene glycol presence, this biological interference could thus be used as a surrogate of costly and highly specialised dosages.
Extracorporeal circulation (ECC) has to ensure homeostasis of the patient and to minimize pathophysiological disorders inherent in the technique. However, we cannot dissociate it from the surgery and anesthesia knowing t...Extracorporeal circulation (ECC) has to ensure homeostasis of the patient and to minimize pathophysiological disorders inherent in the technique. However, we cannot dissociate it from the surgery and anesthesia knowing that the discipline involves a close partnership with these stakeholders. The purpose of this publication is to review the essential elements that at present can contribute to the quality of the CEC and suggest improvements and developments to be implemented in this area.
Cardiac surgery frequently requires blood transfusion. The use of transfusion should be restricted due to side effects. Blood transfusion via the cardiopulmonary bypass (CPB) circuit is easy and allows a fast transfusion...Cardiac surgery frequently requires blood transfusion. The use of transfusion should be restricted due to side effects. Blood transfusion via the cardiopulmonary bypass (CPB) circuit is easy and allows a fast transfusion. The administration of packed red cells is relatively frequent because of the CPB-induced hemodilution and of the higher rate of postoperative complications when the haematocrit during CPB decreases below 20%. This transfusion of packed red cells does not seem to be associated with complications during CPB. Platelet transfusion during bypass is illogical because of the destruction of platelets during CPB and must be avoided. Fresh frozen plasma transfusion during CPB is seldom indicated but is possible. It could reverse heparin resistance.
Cardiac surgery and cardiopulmonary bypass (CPB) have made significant progress in recent years. Despite these efforts, adverse events continue to occur during surgery. From recent studies of incidents and accidents duri...Cardiac surgery and cardiopulmonary bypass (CPB) have made significant progress in recent years. Despite these efforts, adverse events continue to occur during surgery. From recent studies of incidents and accidents during CPB, this article focuses on critical recommendations to respect when in charge of a CPB. Some facts are based only on data unsupported by scientific research. Others have not proven their benefit in terms of postoperative morbidity or mortality. The management of anticoagulation, hematocrit, pump flow, and the temperature is discussed. Finally, the importance of teamwork especially in terms of cohesion and communication is highlighted.
BACKGROUND: Preoxygenation aims to obtain an expired oxygen fraction (FEO2)≥90%. Little is known about the incidence and predictors of inadequate preoxygenation in the clinical setting. PATIENTS AND METHODS: Over a 12-mo...BACKGROUND: Preoxygenation aims to obtain an expired oxygen fraction (FEO2)≥90%. Little is known about the incidence and predictors of inadequate preoxygenation in the clinical setting. PATIENTS AND METHODS: Over a 12-month period, 1050 consecutive preoperative patients were prospectively included. Preoxygenation was performed for 3minutes with a facial mask using a machine circuit and 12-L/min oxygen flow. Inadequate preoxygenation was defined as an FEO2<90%. A logistic regression was performed to identify incidence and independent predictors. RESULTS: The patient characteristics were: age 51±20years, 47% male, BMI of 26±5kg/m(2), and ASA score (median [extremes]) of 2 [1-4]. Inadequate preoxygenation was observed in 589 patients (56%). The effective FiO2 delivered was lower in the patients with inadequate preoxygenation than in those with adequate preoxygenation, 95±3% vs. 98±2%, P<0.001. The difference between the FiO2 and the FEO2 was higher (12±6% vs. 6±3%, P<0.0001) in patients with inadequate preoxygenation compared with those with adequate preoxygenation. The independent risk factors for inadequate preoxygenation were: firstly, bearded male (odds ratio [OR] of 9.1 [2.7-31.4] P<0.001); secondly, beardless male (OR 2.4 [1.6-3.4] P<0.001), thirdly, ASA score of 4 (OR 9.1 [2.6-31.2] P<0.015); fourthly, ASA score of 2-3 (OR 2.4 [1.6-3.4] P<0.015); fifthly, lack of teeth (OR 2.4 [1.2-4.5] P<0.006), and lastly age>55 years (OR 1.8 [1.2-2.7] P<0.005). CONCLUSION: Inadequate preoxygenation, defined as an FEO2 <90% despite 3-min tidal volume breathing, was a common occurrence. The predictive factors share an overlap with those previously identified for difficult mask ventilation.
OBJECTIVE: The aim of this study was to compare the effect of sevoflurane and propofol on cerebral oxygenation, using regional cerebral oxygen saturation (SrO2) measured by near-infrared spectroscopy (NIRS). STUDY DESIGN...OBJECTIVE: The aim of this study was to compare the effect of sevoflurane and propofol on cerebral oxygenation, using regional cerebral oxygen saturation (SrO2) measured by near-infrared spectroscopy (NIRS). STUDY DESIGN: Prospective, randomized, controlled study. PATIENTS AND METHODS: Fifty-four patients aged between 18 and 65 years who underwent elective minor surgery (tumorectomy for breast cancer or inguinal hernia repair) were randomly assigned to receive sevoflurane or propofol anaesthesia. Exclusion criteria included pre-existing cerebrovascular diseases, anaemia, ASA >III, blood loss ≥200 mL, arterial hypotension, baseline pulse oximetry <97%, sign of sensor low quality of SrO2 or bispectral index, and patients with a forehead area <6.5cm. SrO2, bispectral index, haemodynamic data and anaesthetic doses were recorded during surgery. RESULTS: A total of 48 patients were included in the final analysis (24 in each group). There were no significant differences in mean, minimum and maximum SrO2 between sevoflurane and propofol groups. The relative maximum decrease was higher in propofol anaesthesia than sevoflurane anaesthesia (9.6±10.7 versus 4.2±7.2%; P=0.048). Cerebral desaturation (20% reduction from SrO2 baseline during 15 seconds) occurred in 4 patients in propofol group exclusively (P=0.109). SrO2 adjusted for baseline was higher in the sevoflurane group than in the propofol group (67.3±1.8% versus 64.2±1.7%; P=0.018). There were no significant differences in haemodynamic parameters between the two groups. CONCLUSIONS: Cerebral cortical oxygenation measured by NIRS may be better preserved with sevoflurane than with propofol. These findings suggest that sevoflurane anaesthesia could be a good option in patients with compromised cerebral oxygenation, given the absence of intracranial hypertension. Further studies with larger sample sizes are required to support our results.
OBJECTIVES: Endotracheal tube (ETT) and its inflated cuff are likely to induce specific reactivity at the emergence time. In ICU, the tolerance of the ETT cuff could be a part of patient agitation and increased of sedati...OBJECTIVES: Endotracheal tube (ETT) and its inflated cuff are likely to induce specific reactivity at the emergence time. In ICU, the tolerance of the ETT cuff could be a part of patient agitation and increased of sedation. MATERIALS AND METHODS: Using specific ICU ETT cuff (thin polyurethane cuff), we perform an in vitro evaluation of diffusion of lidocaine and alkalinized lidocaine (L-B) across the PU cuff for a long duration. We evaluate the safety of this procedure by a daily injection into the cuff. RESULTS: With lidocaine alone, we observed a low rate of diffusion through the cuff (<8% over 24h), whereas the L-B solution had a high diffusion (>90% over 24h). The released profiles were similar from day 0 to day 8, and no cuff rupture was reported over the 8-day study. CONCLUSION: The safety, controlled release, and lack of deleterious effects on cuff membrane were confirmed. In case of unexpected cuff rupture, an adequate determination of the mixture allows to obtain a safe solution with the achievement of a physiological pH (7.4) and the small dose of lidocaine (40 mg).
Barbe N, Martin P, Pascal J
… +3 more, Heras C, Rouffiange P, Molliex S
Ann Fr Anesth Reanim
· 2014 Mar · PMID 24582109
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OBJECTIVES: Emergency cricothyroidotomy is recommended as life-saving maneuver when mask ventilation and tracheal intubation are impossible. It requires the puncture of the cricothyroid membrane (CTM) whose clinical iden...OBJECTIVES: Emergency cricothyroidotomy is recommended as life-saving maneuver when mask ventilation and tracheal intubation are impossible. It requires the puncture of the cricothyroid membrane (CTM) whose clinical identification is difficult. The objective of this study is to evaluate if ultrasound can help locating the CTM by comparing palpation and ultrasonographic evaluation. PATIENTS AND METHODS: After ultrasound localization of CTM by a referent physician in two overweight volunteers, twelve residents without prior anatomy recall, defined by palpation an entry point for CTM. After a rapid training in CTM ultrasound localization, residents identified an ultrasound-guided puncture point. For each puncture site were registered: relevance, time and ease to localization. Six months later, residents renewed clinical and ultrasound identification of CTM on the same subjects. RESULTS: The CTM was accurately identified by palpation and ultrasound by 46% and 100% of residents respectively (P<0.05). Six months later, residents remained more effective identifying CTM with ultrasound than with palpation (78% vs. 33%) (P<0.05). Time to localization of CTM by palpation in the 2 volunteers was 15 s [11-18] and 24 s [9-39] (average [CI 95%]) whereas it was 21 s [16-25 s] and 28 s [19-36] by ultrasound respectively (ns). The ultrasound identification of CTM was also considered easier than clinical identification. CONCLUSION: Following a limited training phase, ultrasound allowed a more effective localization of CTM by residents when compared to clinical palpation in overweight patients. This benefit remained significant when assessment was repeated 6 months later.