[Perianaesthetic concerns for the new robot-assisted transaxillary thyroid surgery: a report of seven first cases]. / Implications anesthésiques de la chirurgie thyroïdienne ou parathyroïdienne par voie axillaire sous robot-assistance : à propos de sept premiers cas.

The gasless transaxillary robot-assisted endoscopic thyroid surgery is recently proposed and developed in South Corea and USA. We reported the perianaesthestic concerns for the seven first patients scheduled to undergo this innovative surgical technique in France. The anaesthetic considerations focused on the length of surgery according to the learning curve, the risk of the arm posture and the postoperative painful evaluation and relief.

The preoperative administration of ketoprofen improves analgesia after laparoscopic cholecystectomy in comparison with propacetamol or postoperative ketoprofen.

BACKGROUND: Non-opioid analgesics, paracetamol and non-steroid anti-inflammatory drugs (NSAIDs) are proposed for pain relief after laparoscopy. We compared perioperative propacetamol (P) and ketoprofen (K) to provide analgesia after laparoscopic cholecystectomy. METHODS: After ethical committee approval, we included 104 ASA I-II patients, without preoperative analgesic drugs, who were scheduled to undergo laparoscopic cholecystectomy. Anaesthesia was standardized using propofol, fentanyl, atracurium, isoflurane and N(2)O 50%. Ketoprofen 100 mg or propacetamol 2 g or a saline drip (a 100-ml unit of saline in 10 min) was infused blindly and randomly. Patients received either ketoprofen (group K1) or propacetamol (group P1) before induction of anaesthesia and saline after surgery, or saline before surgery and ketoprofen (group K2) or propacetamol (group P2) after surgery. Postoperative visual analogue pain scores (VAS 0-100 mm) were recorded during 24 h. If VAS was >30, a second dose (placebo, ketoprofen or propacetamol) was infused. Nalbuphine 0.2 mg kg(-1) i.v. was given as rescue analgesic if VAS was > or =50. RESULTS: Ninety-eight patients were studied The number of patients not requiring the second analgesic was greater in K1 (33.5%) than the others (K2 0%, P1 0%, P2 7.5%). VAS scores were significantly lower in K1 (P=0.001), with less nalbuphine consumption compared with P1. VAS and opioid request were similar in K2 and P2. CONCLUSION: Preoperative administration of ketoprofen improves postoperative analgesia after laparoscopic cholecystectomy compared with its postoperative administration and pre- and postoperative propacetamol.

[A multicentre trial of the diagnostic value and cost of electrocardiography in symptoms suggesting arrhythmia with a new event recorder with transtelephonic transmission]. / Etude multicentrique sur l'intérêt et le coût du diagnostic électrocardiographique de symptômes présumés rythmiques utilisant un nouvel enregistreur d'événements avec transmission transtéléphonique.

Events recorders are used for electrocardiographic documentation of symptoms of arrhythmia too sporadic and short lasting to be recorded by 24 hour Holter monitoring. However, there are no French studies comparing the value and cost of event recorders with conventional diagnostic methods. Recently, a new telediagnostic device has become available in France leading to an assessment of the technique. The aim of this study was to determine the value of this event recorder and the cost of diagnostic ECG in the assessment of presumed arrhythmic symptoms such as palpitations or rare tachycardia (<3 episodes per week) of short duration, compared with conventional techniques. Fifty-eight patients with these criteria were randomised, 30 to Survcard (Group I) and 28 to conventional diagnostic methods (Group II). The patients were comparable with respect to age, sex distribution, type of symptoms and associated cardiac disease. The ECG diagnosis of the symptoms was established in 20 cases (66.6%) of patients in Group I in 17 +/- 16 days, and in 14 cases (50.0%) of Group II in 23 +/- 28 days. The difference between the two groups was not statistically significant. The cost of a positive diagnosis for Group I (Survcard) varied from 0 to 228.47 Euro with an average of 71.22 +/- 117.02 Euro. The cost of positive diagnosis in Group II varied from 76.80 to 2340.41 Euro with an average of 480.39 +/- 797.41 Euro. In conclusion, this study showed that the percentage of patients with a positive diagnosis was comparable in the two groups but that the cost was 6 times higher in the group investigated by conventional methods than in the Survcard group because of more costly medical intervention.

[Identification of risk factors for allogenic transfusion in cardiac surgery from an observational study]. / Identification des facteurs prédictifs de transfusion sanguine homologue en chirurgie cardiaque à partir d'une étude observationnelle.

OBJECTIVE: To determine perioperative variables for predicting allogenic transfusion in adult cardiac surgery. STUDY DESIGN: Prospective study. PATIENTS: We included 335 consecutive patients undergoing cardiac surgery between February and April 2001. METHODS: Perioperative variables were prospectively collected in a database. For each patient who received transfusion, hemoglobin threshold for transfusion and total number of units of red cell concentrates were collected. Univariate and multivariate analysis were performed. RESULTS: The two strategies for blood conservation which were predominantly used were aprotinin therapy (78%) and blood salvage from the extracorporeal circuit (68%). During perioperative period, 42% of patients [95% CI: 37-47%] received allogenic transfusion. The haemoglobin threshold for transfusion was 7.4 +/- 1.1 and 8.0 +/- 0.7 g x dl(-1) in operating room and in intensive care unit, respectively. On average, 3.4 +/- 2.7 units of red cell concentrates were transfused perioperatively per patient. Using multivariate analysis, perioperative allogenic transfusion was significantly associated with the following variables: preoperative haemoglobin level < 12 g x dl(-1) (odds ratio 8.9; p = 0.001), emergency procedure (odds = 3.7, p = 0.01), reoperation (odds ratio = 3.3; p = 0.002), chronic obstructive pulmonary disease (odds ratio = 2.5; p = 0.03) and complex surgery (odds ratio = 2.4; p = 0.01). The age, the gender, and body mass index were only independent risk factors by univariate analysis. CONCLUSION: In despite of techniques to limit requirement of allogenic transfusion, a large proportion of cardiac surgical patients remains transfused. Independent risk factors of perioperative transfusion are haemoglobin level < 12 g x dl(-1), emergency procedure, reoperation, chronic obstructive pulmonary disease and complex surgery.

Target-controlled infusion of propofol and remifentanil in cardiac anaesthesia: influence of age on predicted effect-site concentrations.

BACKGROUND: Propofol-anaesthesia administrated via target-controlled infusion (TCI) has been proposed for cardiac surgery. Age-related changes in pharmacology explain why propofol dose requirement is reduced in elderly patients. However, the Marsh pharmacokinetic model incorporated in the Diprifusor propofol device does not take age into account as a covariable. In the absence of depth of anaesthesia monitoring, this limitation could cause adverse cardiovascular effects resulting from propofol overdose in older patients. We assessed the influence of age on effect-site propofol concentrations predicted by the Diprifusor and titrated to the bispectral index score (BIS) during cardiac anaesthesia. METHODS: Forty-five patients received propofol by Diprifusor and remifentanil by software including Minto model. Propofol and remifentanil effect-site concentrations were adapted to BIS (40-60) and haemodynamic profile, respectively. The influence of age on effect-site concentrations was assessed by dividing patients into two groups: young (<65 yr) and elderly (> or =65 yr). RESULTS: For a similar depth of anaesthesia, effect-site propofol concentrations were significantly lower in elderly patients at the different stages of cardiac surgery. The mean dose of propofol required to perform tracheal intubation was significantly lower in elderly patients. However, the overall doses of propofol were comparable in both groups. Neither effect-site remifentanil concentrations nor overall doses of remifentanil were significantly different between the two groups. CONCLUSIONS: In cardiac anaesthesia, target concentrations of propofol must be reduced in elderly patients. Although this probably contributes to improving intraoperative haemodynamic stability, the absence of decrease in overall dose requirement of propofol suggests that this adjustment is relatively moderate.

Pre-emptive lidocaine inhibits arterial vasoconstriction but not vasopressin release induced by a carbon dioxide pneumoperitoneum in pigs.

BACKGROUND: We assessed the preventive effects of i.v. or i.p. lidocaine administration on increases in vascular resistance produced by carbon dioxide pneumoperitoneum and related this to vasopressin release. METHODS: Carbon dioxide pneumoperitoneum (14 mm Hg intra-abdominal pressure) was performed in 32 anaesthetized young pigs and monitored using a pulmonary artery catheter. Animals received lidocaine 0.5% (0.5 mg kg(-1)) i.v. (n=9) or 2 ml kg(-1) i.p. (n=9) or saline (n=5) 15 min before the pneumoperitoneum and were compared with a control group (n=9). RESULTS: I.V. and i.p. lidocaine inhibited increases in mean systemic vascular resistance induced by the pneumoperitoneum [2109 (SD 935) and 2282 (895), respectively, vs 3013 (1067) dyne s(-1) cm(-5) in the control group]. Cardiac output was increased. Plasma lidocaine concentrations were threefold higher after i.p. administration than after i.v. administration. After pneumoperitoneum insufflation, plasma lysine-vasopressin concentrations increased in all groups (control 74%, saline 65%, i.p. lidocaine 57%, i.v. lidocaine 74%). CONCLUSIONS: I.V. and i.p. lidocaine blunted systemic vascular responses to carbon dioxide pneumoperitoneum in pigs, but without influencing vasopressin release.

[Cardioversion by external electric shock for atrial fibrillation: does patient age affect immediate results?]. / Cardioversion par choc électrique externe de la fibrillation auriculaire: l'âge des patients affecte-t-il les résultats immédiats?

The restoration of sinus rhythm by external electric shock in patients with persistent atrial fibrillation is a well established treatment. However, in current practice this treatment is generally indicated less in the elderly subject although this attitude is not factual. The objective of this work was to evaluate the immediate results of cardioversion by external electric shock, comparing the success rates in four age groups: under 60 years, between 60 and 69 years, between 70 and 79 years, and over 80 years. This study was performed on 182 consecutive patients aged from 25 to 89 years: 35 patients aged less than 60 years, 52 patients aged from 60 to 69 years, 65 patients aged from 70 to 79 years, and 30 patients aged 80 years or over. The success rates were 91.4% before 60 years, 90.4% between 60 and 69 years, 90.8% between 70 and 79 years, and 83.3% after 80 years. There was no significant difference between the success rates in the four age groups (p = 0.68). Among the other factors analysed, only the duration of atrial fibrillation and the body mass index significantly influenced the results of external electric shock in this series. This work suggests that age does not significantly influence the immediate results of external electric shock. According to these data it does not appear justified to contra-indicate cardioversion by external electric shock on the sole criterion of age.

Patient-controlled epidural analgesia after abdominal surgery: ropivacaine versus bupivacaine.

UNLABELLED: In this randomized, double-blinded study we sought to assess the analgesic efficacy of ropivacaine and bupivacaine in combination with sufentanil and the efficacy of ropivacaine alone after major abdominal surgery. Sixty patients undergoing major abdominal surgery received standardized general anesthesia combined with epidural thoracic analgesia. They were allocated to one of three groups: the BS group received postoperative patient-controlled epidural analgesia with 0.125% bupivacaine plus 0.5 microg/mL sufentanil; the RS group received 0.125% ropivacaine plus 0.5 microg/mL sufentanil; and the R group received 0.2% ropivacaine, with the patient-controlled epidural analgesia device set at bolus 2-3 mL and background infusion 3-5 mL/h. Visual analog scale scores were significantly lower during coughing in the BS group compared with the RS and R groups and in the RS group compared with the R group. The BS group required significantly less local anesthetic (milligrams per day) during the first three postoperative days compared with the RS and R groups, and the RS group, significantly less than the R group. No major side effects were noted in any group. We conclude that, after major abdominal surgery, thoracic epidural analgesia was more effective with bupivacaine than with ropivacaine when these two local anesthetics are used in a mixture with sufentanil. Ropivacaine alone was less effective than ropivacaine in combination with sufentanil. IMPLICATIONS: After major abdominal surgery, thoracic epidural analgesia was more effective with 0.125% bupivacaine than with 0.125% ropivacaine when these two local anesthetics were used in a mixture with 0.5 microg/mL sufentanil. Ropivacaine 0.2% alone was less effective than 0.125% ropivacaine combined with sufentanil.

Haemodynamic and renal effects of intravenous enalaprilat during coronary artery bypass graft surgery in patients with ischaemic heart dysfunction.

Renal dysfunction occurring after open heart surgery is multifactorial in origin but activation of the renin-angiotensin system may have a prominent role. Fourteen patients with ischaemic heart dysfunction scheduled for elective coronary artery bypass graft (CABG) surgery were allocated to a treatment group [enalaprilat for 2 days; ACEI (angiotensin-converting enzyme inhibitor) group, n=7] or a control group (n=7). The cardiac index was significantly higher in ACEI-treated patients than in the controls before and after cardiopulmonary bypass (CPB) (P<0.05) and on postoperative day 2 (P<0.05). The systemic vascular resistance was significantly lower in the ACEI-treated patients than in the controls before and after CPB (P<0.05). Renal plasma flow, measured as [131I]orthoiodohippuran clearance (ClH), was higher in the ACEI group than in the control group before CPB, as was endogenous creatinine clearance after CPB (P<0.05). On post-operative day 7, ClH was significantly higher in the ACEI group than in the control group (P<0.05). Plasma renin activity and vasopressin concentration increased in both groups during CPB (P<0.05). The study demonstrates that administration of an i.v. ACEI, enalaprilat, improves cardiac output during CABG surgery in patients with ischaemic heart dysfunction. Moreover, renal perfusion was better maintained during surgery, and this effect was sustained up to post-operative day 7.

Terlipressin for treating intraoperative hypotension: can it unmask myocardial ischemia?

IMPLICATIONS: After administration of terlipressin to treat hypotension related to induction of general anesthesia, profound hypertension occurred in association with myocardial ischemia and occlusion of the left anterior descending coronary artery. The authors emphasize cautious use of this drug because of such adverse events.

[Quality assurance program for postoperative pain management: impact of the Consensus Conference of the French Society of Anesthesiology and Intensive Care]. / Programme d'assurance qualité de prise en charge de la douleur postopératoire: impact de la Conférence de consensus de la Sfar.

OBJECTIVE: To assess the impact of a pain management quality assurance program (PQAP) after abdominal surgery. The means used were mainly based on the French Society of anaesthesiology's pain management guidelines. STUDY DESIGN: Prospective evaluation using a before after study design: two audits among surgical patients: a first one in 1997 before implementation of PQAP, and a second one year later. PATIENTS AND METHODS: First, standards were defined including objectives about pain relief and patient satisfaction. After analysis of discrepancy observed between these objectives and the data of the first audit, a pain management program was introduced that included education of physicians, nurses and patients, systematic assessment of pain, organized pain relief protocols and implementation of modern analgesic technologies. RESULTS: 201 consecutive inpatients were evaluated in the first audit, and 117 in the second one. Comparing the second audit with baseline, the visual analog pain scores decreased during the five postoperative days, and the rate of very satisfied patients increased (36% versus 26%). 43% of the patients were given a regular analgesic medication in 1998 versus 15% in 1997. 65% of medications were administered with an effective interval between doses versus 47% in 1997. Patient-controlled techniques were used in 28% of the cases in 1998 versus 9% in 1997. CONCLUSION: The PQAP provided an improvement in efficacy of postoperative pain management in our unit, with the help of the overall ward staff, but without requiring personnel specially qualified.

External cardioversion of atrial fibrillation: comparison of biphasic vs monophasic waveform shocks.

AIMS: It is well established in transthoracic ventricular defibrillation that biphasic truncated waveform shocks are associated with superior defibrillation efficacy when compared with damped sine wave monophasic waveform shocks. The aim of this study was to explore whether biphasic waveform shocks were superior to monophasic waveform shocks for external cardioversion of atrial fibrillation (AF). METHODS AND RESULTS: Fifty-seven patients in whom cardioversion of AF was indicated were randomized in this prospective study, to transthoracic cardioversion with either monophasic damped sine waveform shocks or biphasic impedance compensating waveform shocks. In the group randomized to monophasic waveform shocks (27 patients), a first shock of 150 J was delivered, followed (if necessary) by a 360 J shock. In the biphasic waveform group (30 patients), the first shock had an energy of 150 J and (if necessary) a second 150 J was delivered. All shocks were delivered in the anterolateral chest pad position. Sinus rhythm was restored in 16 patients (51%) with the first monophasic shock and in 27 patients (86%) with the first biphasic shock. The difference was statistically significant (P=0.02). After the second shock, sinus rhythm was obtained in a total of 24 patients (88%) with monophasic shocks and in 28 patients (93%) with biphasic shocks. No complication was observed in either group and cardiac enzymes (CK, CKmb, troponin I, myoglobin) did not show any significant changes. CONCLUSION: This study suggests that at the same energy level of 150 J, biphasic impedance compensating waveform shocks are superior to monophasic damped sine waveform shocks cardioversion of atrial fibrillation.

[Thrombopenia increased by heparin and danaparoid]. / Thrombopénie croisée aux héparines et au danaparoïde.

Pathogenesis, frequency, and management of heparin-induced thrombocytopaenia are well-known. They may be related with both unfractioned heparin and low-molecular weight heparin. Suspected heparin must be discontinued as soon as the diagnosis is established. Orgaran (danaparoid sodium) may be used for management of patients with heparin-associated thrombocytopaenia but can itself be associated with a thrombocytopaenia. Our case report allows us to catch in mind such a crossed complication.

Monitoring of end-tidal carbon dioxide partial pressure changes during infrarenal aortic cross-clamping: a non-invasive method to predict unclamping hypotension.

BACKGROUND: To assess the variations in end-tidal CO2 in response to aortic cross-clamping and the relationship with systolic arterial pressure (SAP) changes induced by unclamping. METHODS: Thirty-three patients undergoing infrarenal aortic abdominal aneurysm repair by aorto-aortic prothetic bypass were prospectively studied. All patients were anesthetized with i.v. midazolam (0.05 mg x kg(-1)), thiopentone (3-5 mg x kg(-1)), fentanyl (5 microg x kg(-1)), pancuronium (0.1 mg x kg(-1)) and the maintainance of anesthesia used was 1-1.5% end-tidal isoflurane and i.v. fentanyl. The perioperative management was standardized. End-tidal CO2 and SAP were measured 5 min before (Pre-XAA), 15 min after infrarenal aortic cross-clamping (XAA), 5 min before (Pre-UXAA) and immediately after unclamping (UXAA). RESULTS: A total of 16 (48.5%) from 33 patients presented decrease in SAP following aortic unclamping, and 13 out of these patients had arterial hypotension defined as SAP<90 mmHg. End-tidal CO2 variation (PreXAA-PreUXAA) induced by aortic clamping was correlated with SAP variation (PreUXAA-UXAA) induced by unclamping (r=0.763; P=0.0001). An end-tidal CO2 reduction above 15% after aortic cross-clamping was found to have a 100% sensitivity to detect a SAP decrease greater than 20% after unclamping, with a 100% specificity and a negative predictive value of 1.0. Complete aortic occlusion duration was not correlated to SAP unclamping variation (deltaSAP). Intraoperative characteristics (fluid loading, hematocrits, urinary output) were comparable, although blood loss was higher in patients experiencing deltaSAP>20%. CONCLUSIONS: End-tidal CO2 variation monitoring during aortic cross-clamping may provide a reliable and non-invasive method to predict unclamping hypotension. When the aortic clamp was released, systolic hypotension (>20%) occurred in those subjects who had a decrease in end-tidal CO2 greater than 15% during aortic cross-clamping.

[Endovascular treatment of aorto-iliac aneurysms. Made-to-measure endoprotheses increase the feasibility]. / Traitement endovasculaire des anévrismes aorto-iliaques. La confection astisanale sur mesure des endoprothèses augmente le taux de faisabilité.

The authors describe their experience of tailoring endoprostheses for endovascular treatment of aorto-iliac aneurysms with components available on the market. Between January 1996 and December 1999, 188 aorto-iliac aneurysms were treated by tailor-made endoprostheses using self-expanding Z stents made of stainless steel compiled with polyester ligatures and covered with standard commercially available polyester prostheses. These endoprostheses were implanted with an 18 to 24 Fr (usually 20 Fr) introducer and positioned by a surgical approach. This method allows construction of tubular, bifurcated, digressive or occlusive endoprostheses associated with an extra-anatomical bypass graft. It increased the number of endovascular procedures for aorto-iliac aneurysms in the authors' department. This number has been further increased by using endoprostheses with an uncovered proximal or distal stent for cases with particularly short or angled necks and by using hybrid endoprostheses with one or more extremities without a stent, allowing surgical suture of the anastomosis. The authors' results show that tailoring endoprostheses considerably increased the feasibility of endovascular treatment of aorto-iliac aneurysms, even in unselected patients whilst providing an effectiveness and safety to justify the continuation of this experience.

[Is atypical sodium current related to arterial pathophysiology?]. / Un courant sodique atypique lié à la patho-physiologie artérielle?

Primary cultured human coronary myocytes, derived from patients with end-stage heart failure (NYHA, classes III and IV) caused by an ischemic disease and undergoing heart transplantation, express a voltage-gated tetrodotoxin-sensitive sodium current (INa). This current has atypical electrophysiological and pharmacological properties and regulates intracellular sodium ([Na+]i) and calcium ([Ca2+]i). Our work is aimed at identifying its role and regulation of expression during pathophysiology. We currently investigate whether INa is expressed in vascular smooth muscles cells (VSMCs) isolated from either healthy or diseased (atheromatous) arteries in human and, in parallel, in pig, rabbit and rat. Cells were enzymatically isolated, primary cultured and macroscopic INa were recorded using the whole cell patch clamp technique. We found that INa is expressed in VSMCs grown from human aortic (90%; n = 48) and pulmonary (44%; n = 16) arteries and in the human aortic cell line HAVSMC (94%; n = 27). INa was also detected in pig coronary (60%; n = 25) and rabbit aortic (47%; n = 15) VSMCs, but not in rat aortic myocytes (n = 30). These different INa were activated at similar range of potentials (approximately -45 mV), had similar sensitivity to tetrodotoxin (IC50 around 5 nM) and similar density (2 to 4 pA/pF). Their expression was related to cell dedifferentiation in vitro. However, INa was observed more frequently in human myocytes derived from diseased arteries (ischemic cardiopathy) than in those derived from healthy tissues (dilated cardiopathy). In conclusion, INa may contribute to increase the basal arterial contractility and play a role in pathological situations including hypertension.