Feasibility of closed-loop co-administration of propofol and remifentanil guided by the bispectral index in obese patients: a prospective cohort comparison.

BACKGROUND: We used an automated bispectral index (BIS)-guided dual-loop controller to determine propofol and remifentanil requirements during general anaesthesia in obese and lean surgical patients. METHODS: Obese patients, BMI>35 kg m(-2), and lean patients (<25 kg m(-2)) having laparoscopic procedures were prospectively evaluated in this multicentre single-blind study. The automated controller targeted BIS between 40 and 60 by adjusting propofol and remifentanil administration. Propofol and remifentanil consumptions were calculated using both total body weight (TBW) and ideal body weight (IBW). Results are expressed as medians (inter-quartile range). RESULTS: Thirty obese [BMI=43 (40-49) kg m(-2)] and 29 lean [BMI=23 (21-25) kg m(-2)] patients completed the study. BIS was between 40 and 60 during 84 (69-91)% vs 85 (78-92)% of the anaesthetic time, P=0.46. The amount of propofol given during induction [1.2 (1.1-1.6) vs 1.3 (1.0-1.7) mg kg(-1), P=0.47] and maintenance [5.2 (4.1-6) vs 5.3 (4.7-6.4) mg kg(-1) h(-1), P=0.39] calculated using TBW was similar between the two groups. The dual-loop controller delivered half as much remifentanil to the obese patients during induction [1.0 (0.8-1.6) vs 2.2 (1.5-2.7) µg kg(-1), P<0.001] and maintenance [0.12 (0.07-0.16) vs 0.25 (0.17-0.29) µg kg(-1) min(-1), P<0.001] calculated using TBW. But when remifentanil consumption was calculated using IBW, the amounts were similar during induction at 2.2 (1.6-3.5) vs 2.0 (1.6-3.0) µg kg(-1) IBW, P=0.48, and during maintenance at 0.26 (0.16-0.34) vs 0.27 (0.18-0.33 ) µg kg(-1) min(-1), P=0.50. CONCLUSIONS: The amount of propofol-remifentanil administered by the controller is consistent with current knowledge, propofol is best dosed using TBW whereas remifentanil is best dosed using IBW. CLINICAL TRIAL REGISTRATION: NCT00779844.

Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience.

AIM: Neuroprotective effects of hypothermia may explain surprisingly high survival rates reported after drowning in cold water despite prolonged submersion. We described a cohort of refractory hypothermic cardiac arrests (CA) due to drowning treated by extracorporeal life support (ECLS) and aimed to identify criteria associated with 24-h survival. METHODS: Eleven-year period (2002-2012) retrospective study in the surgical intensive care unit (ICU) of a tertiary hospital (European Hospital Georges Pompidou, Paris, France). All consecutive hypothermic patients admitted for refractory CA after drowning in the Seine River were included. Patients with core temperature below 30°C and submersion duration of less than 1h were potentially eligible for ECLS resuscitation. RESULTS: Forty-three patients were admitted directly to the ICU during the study period. ECLS was initiated in 20 patients (47%). Among these 20 patients, only four (9%) survived more than 24h. A first hospital core temperature ≤26°C and a potassium serum level between 4.2 and 6mM at hospital admission have a sensitivity of 100% [95%CI: 28-100%] and a specificity of 100% [95%CI: 71-100%] to discriminate patients who survived more than 24h. Overall survival at ICU discharge and at 6-months was 5% [95%CI: 1-16%] (two patients). CONCLUSIONS: Despite patient hypothermia and aggressive resuscitation with ECLS, the observed survival rate is low in the present cohort. Like existing algorithms for ECLS management in avalanche victims, we recommend to use first core temperature and potassium serum level to indicate ECLS for refractory CA due to drowning.

[Burnout-associated factors in anesthesia and intensive care medicine. 2009 survey of the French Society of anesthesiology and intensive care]. / Facteurs associés au burnout en anesthésie-réanimation. Enquête 2009 de la Société française d'anesthésie et de réanimation.

OBJECTIVE: To assess factors related to burnout in anesthesia and intensive care. DESIGN: National prospective observational study. MATERIALS AND METHODS: Questionnaire posted on the French Society of anesthesia website from 3rd June 2009 to 27th August 2009: Maslach Burnout Inventory (MBI), Fast Alcohol Consumption Evaluation (FACE) and The Harvard National Depression Screening Day Scale (HANDS) scales and questions to assess health, work and personal life. RESULTS: One thousand six hundred and three questionnaires returned: 1091 anesthetists (67.6%), 241 intensivists (14.9%), 204 nurses (12.6%), emergency physicians (2.8%), supervisor nurses (0.9%). Seven hundred and sixty three in a university hospital (47.3%), 259 in a regional hospital (16.1%), 405 in a private structure (25.1%), 71 in a non-lucrative private structure (4.4%), 75 in a military hospital (4.6%). Rest of safety: 69.2% of institutions. Depression: 38.7%. Drug or chemicals addicted: 10.6%. Alcohol addicts: 10.6%. Among them, 62.3% of individuals were in burnout. Burnout was linked to fragmented sleep (P<0.00001), interpersonal conflicts (P<0.00001), perception of rest of safety (P<0.02), mental history (P<0.00001), suicidal ideations (P<0.00001), depression (P=0.00001), alcohol (P<0.002), drug consumption (P<0.00002), and accidents after a nightshift (P<0.05). Subjects in burnout intended more frequently to leave the profession (P<0.00001). Leaving in couple had a protective effect (P<0.005). The logistic regression model retained seven covariates independently associated with burnout: quality of work, of personal life, of fatigue, depression, conflicts with colleagues and patients, regretting the choice of specialty. CONCLUSION: This study of the largest cohort of anesthesia personnel performed in France detects a high proportion of burnout. It highlights links with tensors that may constitute possibilities of prevention of the burnout syndrome.

Hyperthermic isolated liver perfusion with melphalan and bevacizumab.

Whereas surgical resection is the only curative treatment for liver tumors, effective treatment for isolated unresectable lesions when there is tumor progression in spite of several lines of chemotherapy remains to be found. We report herein two cases of patients treated by a 1-hour Hyperthermic Isolated Liver Perfusion (HILP) with a combination of melphalan and bevacizumab leading to complete response. The first patient had liver metastases secondary to previously resected malignant glucagonoma and the second, recurrent hepatocellular carcinoma. We used bevacizumab in association with melphalan for HILP because of the additional effect of an anti-VEGF antibody in these highly vascularized tumors and its locally restricted delivery to the isolated hepatic vascular compartment despite of its classic contraindication in association with surgery. The protocol was approved by the Ethics Committee. Enhanced CT scans during follow-up showed complete tumor necrosis as early as the second postoperative day. Patients had 27 and 7 months disease-free survival and 48 and 41 months overall survival after HILP, for neuroendocrine liver metastases and HILP plus liver transplantation for HCC respectively. Under very specific conditions, bevacizumab in HILP can provide excellent tumor response in hopeless clinical cases of liver tumors.

[Second wave of the French drug harmonisation programme to prevent medication errors: overall appreciation of healthcare professionals]. / Évaluation de l'impact auprès des professionnels de la mise en œuvre de la seconde vague du plan d'harmonisation de l'étiquetage des injectables.

BACKGROUND: Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008-2009 by a second wave concerning 42 active drugs. METHODS: The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals. RESULTS: The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians. CONCLUSION: This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors.

[The anaesthesia and critical care specialty and new hospital management in France: an inquiry in university and general hospitals]. / La discipline anesthésie-réanimation et les pôles d'activité médicale (PAM) : résultats d'une enquête auprès des CHU et CHG.

OBJECTIVE: To know: (1) how French public services of anaesthesia and critical care (ACC) have applied the new principles of hospital management and (2) whether or not it has impacted the different components of ACC. STUDY DESIGN: National questionnaire at the end of 2008, i.e., after 2 years of new hospital management. MATERIAL: Heads of ACC services in general (GH) and university hospitals (UH). METHODS: Eighteen closed questions and open opinions analyzed. Comparisons of percentages (Chi(2) - Yates): linear correlation. RESULTS: Percentages of responses were 70% (n=51) for UH and 37% (n=146) for GH. The new management principles were mainly applied. The different clinical and academic components of the ACC specialty (ACC, emergency medicine, pain management) mainly remained associated in UH. In GH, the new management induced constant and various changes. They were mainly judged as defeating the object of the ACC speciality in GH, especially in those of lower and mild sizes. CONCLUSION: The general tendency is that the ACC specialty was able to maintain the family ties of its different components in the UH. However, this principle was not a cornerstone of the new management in the GH.

[Field 7. Safety practice for renal-replacement therapies. French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation]. / Champ 7. Sécurisation des procédures d'épuration extrarénale. SRLF. SFAR.

Renal-replacement therapies are among the most invasive techniques used in the intensive-care units. An increased security of these methods can be expected from interventions on several areas. Teaching and training are probably the more important due to the complexity of both techniques and devices. The interest and the limits of the monitoring techniques need to be known as well as the guidelines for an optimal ordering. As often, a set of written procedures must ideally be constructed by the ICU team then learned and periodically revised.

Pressure-controlled ventilation improves oxygenation during laparoscopic obesity surgery compared with volume-controlled ventilation.

BACKGROUND: We compared pressure and volume-controlled ventilation (PCV and VCV) in morbidly obese patients undergoing laparoscopic gastric banding surgery. METHODS: Thirty-six patients, BMI>35 kg m(-2), no major obstructive or restrictive respiratory disorder, and Pa(CO(2))<6.0 kPa, were randomized to receive either VCV or PCV during the surgery. Ventilation settings followed two distinct algorithms aiming to maintain end-tidal CO(2) (E'(CO(2))) between 4.40 and 4.66 kPa and plateau pressure (P(plateau)) as low as possible. Primary outcome variable was peroperative P(plateau). Secondary outcomes were Pa(O(2)) (Fi(O(2)) at 0.6 in each group) and Pa(CO(2)) during surgery and 2 h after extubation. Pressure, flow, and volume time curves were recorded. RESULTS: There were no significant differences in patient characteristics and co-morbidity in the two groups. Mean pH, Pa(O(2)), Sa(O(2)), and the Pa(O(2))/Fi(O(2)) ratio were higher in the PCV group, whereas Pa(CO(2)) and the E'(CO(2))-Pa(CO(2)) gradient were lower (all P<0.05). Ventilation variables, including plateau and mean airway pressures, anaesthesia-related variables, and postoperative cardiovascular variables, blood gases, and morphine requirements after the operation were similar. CONCLUSIONS: The changes in oxygenation can only be explained by an improvement in the lungs ventilation/perfusion ratio. The decelerating inspiratory flow used in PCV generates higher instantaneous flow peaks and may allow a better alveolar recruitment. PCV improves oxygenation without any side-effects.

[European normative recommendations for medical gas pipeline systems]. / Normalisation européenne et systèmes de distribution de gaz médicaux.

Several recent decisions have been made in order to increase the security of medical gases delivery in French hospitals. These different changes affect: 1) the hospital itself with the creation of working groups in charge of both monitoring and maintenance of gases networks; 2) the pharmaceutical regulation with promotion of several gases to the status of drugs or need of CE marking for the whole gas network. European rules onset required to give up French former norms (NF) to the profit of "NF EN" rules. Nevertheless, the new norm NF EN 737-3 which concerns medical gases distribution systems does not affect principal clauses of the previous NF S 90-155. It introduces new elements allowing to deploy two types of medical gases networks: the double pressure level used in France and the single pressure level used in the rest of Europe. This new norm, which attempts to harmonize alarm control systems in both types of networks, suffers from important limitations describing the double pressure level systems. Lastly, the final checking proposed by this new norm is very different from the previous one, and is likely to be problematic for the final users within the hospital.

[Abdominal aorta lesion during surgical treatment of a foraminal disk hernia]. / Plaie de l'aorte abdominale au cours d'une cure de hernie discale.

We report a case of an abdominal aorta lesion on a 54-year-old woman, who underwent surgery for the treatment of a foraminal disk hernia. At the end of the hernia repair, a sudden hypovolaemic collapse occurred. A computed tomography revealed an abdominal aorta disruption and a retroperitoneal haematoma. An endovascular treatment was preferred to a surgical reintervention and an endoluminal stent-graft was inserted; the postoperative course was uneventful. This case report describes an example of vascular complications of disk hernia surgery which are rare but potentially serious. It emphasizes the increasing development of endovascular procedures and their utility in the treatment of acute contained aortic disruption.

High-volume haemofiltration in human septic shock.

OBJECTIVE: To evaluate whether high volume haemofiltration improves haemodynamics and affects serum cytokine and complement concentrations in human septic shock. DESIGN AND SETTING: Randomized cross-over clinical trial in a tertiary intensive care unit. PATIENTS: Eleven patients with septic shock and multi-organ failure. INTERVENTIONS: Patients were assigned to either 8 h of high-volume haemofiltration (HVHF; 6 l/h) or 8 h of standard continuous veno-venous haemofiltration (CVVH; 1 l/h) in random order. MEASUREMENTS AND MAIN RESULTS: We measured changes in haemodynamic variables, dose of norepinephrine required to maintain a mean arterial pressure greater than 70 mmHg and plasma concentrations of complement anaphylatoxins and several cytokines. An 8-h period of HVHF was associated with a greater reduction in norepinephrine requirements than a similar period of CVVH (median reduction: 10.5 vs. 1.0 microg/min; p = 0.01; median percentage reduction: 68 vs. 7%; p = 0.02). Both therapies were associated with a temporary reduction (p < 0.01) in the plasma concentration of C3a, C5a, and interleukin 10 within 2 h of initiation. HVHF was associated with a greater reduction in the area under the curve for C3a and C5a (p < 0.01). The concentration of the measured soluble mediators in the ultrafiltrate was negligible. CONCLUSIONS: HVHF decreases vasopressor requirements in human septic shock and affects anaphylatoxin levels differently than standard CVVH.

[Comparison of two measurement methods: the Bland and Altman assessment]. / Comparaison de deux méthodes de mesure d'une même grandeur: méthode de Bland et Altman.

Bland-Altman analysis for comparison of two methods of clinical measurement is frequently used in scientific publications. This article is more appropriate than the conventional linear regression analysis. This paper gives an overview of the principles for the use of Bland-Altman analysis as well as the specific terminology attached to it. The Bland-Altman comparison analysis is mainly a tool for clinical interpretation. The bias and the agreement limits provide the variation of the values of the technique compared to the other. The difference between the two methods of measurement is plotted against the average obtained with each of the two techniques. Bland-Altman analysis can also be used to check the repeatability of a measurement technique within the same subject and to determine a repeatability coefficient. With an adaptation of the calculation of the agreement limits, the average of multiple measurements for each subject with two measurement techniques can be used for the Bland-Altman analysis.

Hemofiltration during cardiopulmonary bypass.

Several factors combine to facilitate the evolution towards heart and multi-organ failure following cardiac surgery. Some of these factors are related to pure cardiac aspects like the existence of a preoperative heart disease, the use of aortic cross clamping or performance of cardiotomy. Cardiopulmonary bypass (CPB) also plays an important role in the occurrence of postoperative organ dysfunctions by two principal means: firstly by inducing a profound hemodilution, which impairs oxygen transport through tissues. This phenomenon is pointed out in the postoperative period by the existence of increased transpulmonary O2 gradients, extravascular lung water volume and subsequent impairments of O2 transport. Secondly CPB is deleterious by triggering an important inflammatory reaction. This reaction is largely related to the ratio of the circuit area to the patient's body surface area and is therefore maximal in children. It has been widely demonstrated that the very early paths of this reaction imply several humoral factors including kinins, coagulation factor-XII and complement fragments. The activation of these factors is self-amplified and triggers both expression and release of numerous mediators by endothelial cells and leukocytes. Finally, these mediators are responsible for the well described "post-bypass syndrome" which is, from a clinical viewpoint, very close to hyperkinetic septic shocks. Several methods have been proposed to reduce the deleterious effects of both cardiac surgery and CPB. The older one is hypothermia that considerably reduces the triggering of the inflammatory mediators network. Heparin-coated circuits may also reduce this reaction to some extent. Hemofiltration has been introduced in the 90's in CPB management. Because of its very high tolerance in patients with compromised circulatory status this technique was already used in the postoperative period to treat patients with acute renal failure. Initially hemofiltration was intended to correct the accumulation of extravascular water during or immediately following the surgical procedure. Nevertheless several of its "side-effects" appeared to be useful like reduction of postoperative blood loss and immediate hemodynamics improvement. Several studies attempted to point out the mechanism of action of hemofiltration and although removal of inflammatory mediator occurs, there is currently no proofs that this removal is the actual mechanism by which this technique acts. At the early beginning of the use of its utilization hemofiltration during cardiac surgery aimed either to concentrate blood at the end of the procedure or to rapidly restore a normal fluid and electrolytes balance. Today some new implementations of this technique are proposed either to reduce the triggering of the inflammatory reaction to CPB or to reduce the immediate postoperative drug support.

Incidence and predictors of major hemorrhagic complications from thrombolytic therapy in patients with massive pulmonary embolism.

PURPOSE: The risk factors for bleeding in patients receiving recombinant tissue-type plasminogen activator for massive pulmonary embolism are not known. PATIENTS AND METHODS: The hospital records of 132 consecutive patients who received recombinant tissue-type plasminogen activator for massive pulmonary embolism were retrospectively reviewed. Bleeding was estimated by using the bleeding severity index, a method previously validated in patients receiving anticoagulants. Multivariate stepwise logistic regression was used to identify independent risk factors for bleeding. Four other definitions of bleeding in large pulmonary embolism thrombolytic trials were also used, and the agreement among these criteria was assessed. RESULTS: According to the bleeding severity index, 33 patients (25%) had one or more major bleeding complications. Hemorrhage at the venous puncture site for angiography was the most frequent complication (15 patients, 11%). Major bleeding at the catheterization site was more common at the femoral site (14 of 63 patients = 22%) than at the brachial site (1 of 63 patients = 2%; P = 0.0004). The use of the five different bleeding definitions resulted in a variation in the major bleeding rate from 3% to 43%. The kappa coefficient varied from 0.07 to 0.84, indicating poor agreement between most of the classifications. CONCLUSION: The use of the femoral vein for pulmonary angiography was the only variable significantly associated with major bleeding. Most of the differences observed in the pulmonary embolism thrombolytic trials are likely related to the differences in the definition of bleeding rather than to the thrombolytic regimen.