Validation of the Behavioural Observation Scale 3 for the evaluation of pain in adults.

BACKGROUND: Many behavioural scales are available to assess pain but none are suitable for a quick evaluation of non-sedated and non-geriatric adults. The Behavioural Observation Scale 3 (BOS-3) is short, composed of five items. This study examined its feasibility and diagnostic performances. METHODS: Adult patients were included from medical and surgical departments of the University Hospital of Bordeaux. In a cross-sectional study, BOS-3 was compared to Numerical Rate Scale (NRS) with communicating patients (CP) and Behavioural Scale for the Elderly Person (ECPA2) with non-communicating patients (NCP). Each time, BOS-3 and reference scale were performed by an internal caregiver and an external expert. RESULTS: We included 447 patients: 395 communicating and 52 non-communicating. All patients were assessed by the BOS-3 and the reference test. All BOS-3 were carried out in less than one minute with only four missing data. Its reproducibility (ICC = 0.77 [95% CI 0.73-0.81] with CP and 0.93 [95% CI 0.89-0.97] with NCP) and its internal consistency (Cronbach α = 0.67 with CP and 0.70 with NCP) were good. In non-communicating patients, ROC analysis set a threshold at 3 on 10. Sensitivity was 0.87 [95% CI 0.77-0.96], specificity 0.97 [95% CI 0.93-1.00], positive predictive value 0.93 [95% CI 0.86-0.99] and negative predictive value 0.95 [95% CI 0.89-1.00]. In communicating patients, sensitivity decreased to 0.34 [95% CI 0.28-0.38] but specificity reached 0.96 [95% CI 0.94-0.98] and positive predictive value 0.75 [95% CI 0.70-0.79]. CONCLUSIONS: BOS-3 had good metrological properties in non-communicating adults. With communicating patients, a positive BOS-3 could be an additional tool to confirm pain, when underestimated on the NRS. SIGNIFICANCE: This study describes the diagnostic performances of a behavioral pain assessment scale designed for non-geriatric and non-sedated adults. The results show its validity in non-communicating patients and suggest its usefulness as an ancillary tool in communicating patients in whom simple numerical scales are often insufficient.

Ability of esCCO to track changes in cardiac output.

BACKGROUND: We investigated whether cardiac output measured with pulse wave transit time (esCCO, Nihon Kohden, Tokyo, Japan) is able to track changes in cardiac output induced by an increase in preload (volume expansion/passive leg-raising) or by changes in vasomotor tone (variation in norepinephrine dosage) in critically ill patients. METHODS: Eighty patients for whom the decision to give fluid (500 mL of saline over 15 min) (n=20), to perform passive leg-raising (n=20), and to increase (n=20) or to decrease (n=20) norepinephrine were included by the physician. Cardiac output was measured with pulse wave transit time (CO-esCCO) and transthoracic echocardiography (CO-TTE) before and after therapeutic intervention. RESULTS: Comparison between CO-TTE and CO-esCCO showed a bias of -0.7 l min(-1) and limits of agreement of -4.4 to 2.9 l min(-1), before therapeutic intervention and a bias of -0.5 l min(-1) and limits of agreement of -4.2 to 3.2 l min(-1) after therapeutic intervention. Bias was correlated with systemic vascular resistance (r(2)=0.60, P<0.0001). Percentage error was 61% before and 59% after therapeutic intervention. Considering the overall data (n=80), the concordance rate was 84%, polar plot analysis revealed an angular bias (sd) of -11°(35°) and radial limits of agreement of (sd 50°). With regard to passive leg-raising and volume expansion groups (n=40), the concordance rate was 83%, the angular bias (sd) was -20°(36°) and radial limits of agreement ( 50°). Considering variations in norepinephrine dosage groups (n=40), the concordance rate was 86%, the angular bias (sd) was -1.8°(33°) and radial limits of agreement (40°). CONCLUSIONS: esCCO was not able to track changes in cardiac output, induced by an increase in preload or by variations in vasomotor tone. Therefore, esCCO cannot guide haemodynamic interventions in critically ill patients.

[Cardiac arrest secondary to pacemaker dysfunction during general anesthesia in a young adult patient]. / Arrêt cardiaque sur dysfonction de pacemaker au cours d'une anesthésie générale chez un adulte jeune.

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.

[Preoperative cardiac-risk assessment for non-cardiac surgery: The French RICARDO survey]. / Évaluation du Risque CARDiaque de l'Opéré (RICARDO) : enquête nationale auprès des anesthésistes-réanimateurs concernant la prise en charge périopératoire du patient à risque cardiaque.

OBJECTIVES: Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations. MATERIALS AND METHODS: Since June to September 2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations. RESULTS: We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography. CONCLUSION: This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one.

Target-controlled induction with 2.5% sevoflurane does not avoid the risk of electroencephalographic abnormalities.

BACKGROUND: Epileptiform discharges (ED) can occur during sevoflurane induction, especially in young female patients and when high alveolar concentrations are used. The aim of this study was to evaluate whether low sevoflurane concentration reduces the occurrence of ED in female patients. METHODS: Thirty-four female patients scheduled for minor gynecological surgery were prospectively included and randomized in two groups. In group A, anesthesia was induced with sevoflurane inspired 8% manually set via the circuit of the Zeus(®) (Dräger Medical, Lübeck, Germany) anesthesia workstation (fresh gas flow 8L.min(-1)) for 2min and then 2.5%. In group B, induction was performed by target-controlled inhalation with a target end-tidal concentration of sevoflurane set at 2.5% (fresh gas flow in auto-control mode). Electroencephalogram (EEG) was recorded in the operating room throughout induction till two min after intubation and analyzed off-line by a neurophysiologist blinded to the randomization. RESULTS: ED occurred in five patients (15%): one in group A and four in group B (P>0.05). ED occurred with a median delay of 303 s [25-75 interquartiles: 135-418] and the median duration of ED episode was 13 s [3-78]. Fifteen patients had abnormal movements without simultaneous EEG abnormality. CONCLUSION: Induction of anesthesia with low target concentration of sevoflurane (2.5%) fails to totally prevent the occurrence of ED in young female patients and should be used carefully in this population.

[Epidural labor analgesia and parturient with type 2B von Willebrand disease]. / Analgésie péridurale obstétricale et maladie de Willebrand de type 2B.

Type 2B von Willebrand disease (vWD) is an inherited bleeding syndrome resulting from a qualitative abnormality of von Willebrand Factor with an increased affinity for the glycoprotein Ib platelet receptor. Pregnancy increases the severity of this disease by decreasing the platelet count restricting epidural anaesthesia because of adverse risk of spinal bleeding. There is a phenotypic variability of Type 2B vWD depending of the von Willebrand Factor mutation. We report here the strategy we used to administer epidural anaesthesia for a patient with Type 2B vWD resulting from the P1337L mutation of von Willebrand Factor.

Asymmetry of Bispectral Index (BIS) in severe brain-injured patients treated by barbiturates with unilateral or diffuse brain injury.

OBJECTIVE: Bispectral index (BIS) may be used in traumatic brain-injured patients (TBI) with intractable intracranial hypertension to adjust barbiturate infusion but it is obtained through a unilateral frontal electrode. The objective of this study was to evaluate differences in BIS between hemispheres in two groups: unilateral frontal (UFI) and diffuse (DI) injured. PATIENTS AND METHODS: Prospective monocenter observational study in 24 TBI treated with barbiturates: 13 UFI and 11 DI. Simultaneous BIS and EEG was recorded for 1h. Goal of monitoring was a left BIS between 5 and 15. Biases in BIS were considered as clinically relevant if greater than 5. Differences in biases were interpreted from both statistical (Mann-Whitney test) and clinical points of view. RESULTS: Mean BIS in the two hemispheres remained in the same monitoring range. There were statistic and clinical differences in some values in the two groups of patients (15% of bias greater than I5I in UFI group and 10% in DI group). BIS monitoring allowed the adequate number of bursts/minutes to be predicted in 18 patients and did not detect an overdosage in 2. CONCLUSIONS: While asymmetric BIS values in TBI patients occur whatever the kind of injury, they were not found to be clinically relevant in most of these heavily sedated patients. Asymmetrical BIS monitoring might be sufficient to monitor barbiturate infusion in TBI provided that the concordance between BIS and EEG is regularly checked.

French clinical guidelines on perioperative nutrition. Update of the 1994 consensus conference on perioperative artificial nutrition for elective surgery in adults.

Surgical patient is a stressed patient. Aggression is more intense and prolonged as surgery is important. Surgery induces secretion of stress hormones, inflammatory mediators and metabolic changes resulting in significant catabolic phenomena. The presence of malnutrition is an independent risk factor for postoperative complications. Malnutrition increases morbidity (infections, delayed healing), mortality, length of stay and costs and impacts human quality of life for patients. It has been shown that the management of perioperative malnutrition reduces the additional risk generated by it. Perioperative nutritional support should not be systematically provided. Since 1994, recommendations on perioperative nutrition, the care of patients and the available resources have changed dramatically. An update of these recommendations was needed. In 2010, an expert panel of the French society of Anesthesiology (SFAR) and the French-speaking society of Clinical Nutrition and Metabolism (SFNEP) has made recommendations for good clinical practice of perioperative nutrition. They are presented. Thus, the perioperative nutritional management must be integrated in a process to reduce the operative risk: risk reduction due to preoperative malnutrition, reduced risk of postoperative malnutrition which may compromise the following treatments, reduction of postoperative metabolic complications, reducing the postoperative morbidity, especially infectious, through the use of pharmaconutrients either preoperatively or postoperatively in some patients.

[Catheter-related bladder discomfort in post-anaesthesia care unit]. / Inconfort lié à la sonde vésicale en période postopératoire.

Catheter-related bladder discomfort (CRBD) is an unrecognized clinical event. Symptoms of CRBD secondary to an indwelling urinary catheter mimic those of an overactive bladder, i.e. urinary frequency and urgency with or without urge incontinence. Stimulation of muscarinic receptors located in the bladder wall by the catheter is the triggering factor. Postoperative pain may be increased by the CRBD. Antimuscarinic drugs, as oxybutynin, are today the main treatment. Further studies are warranted to confirm efficacy of ketamine, tramadol and gabapentin in this situation.

[Coronary artery dissection complicated by myocardial infarction in a head trauma patient]. / Dissection coronaire traumatique compliquée d'infarctus du myocarde chez un patient traumatisé crânien.

Acute myocardial infarction, following coronary artery dissection, is a rare, but potentially fatal, syndrome after blunt chest trauma. The treatment is more complicated when intracerebral lesions are present, because of the need of anticoagulation. We report the case of a 37-year-old male patient, suffering from a polytraumatism with intracranial petechial haemorrhages who have a left coronary artery dissection with acute myocardial infarction.

[Nutritional assessment of patients before surgery]. / Évaluation nutritionnelle à la consultation d'anesthésie.

The identification of nutritional status is one of the objectives of the anaesthesia consultation often difficult to achieve routinely. It usually requires the use of multiple indicators, which are complex for a non-nutrition specialist. In preoperative period, nutritional assessment should be easy to do in order to identify patients who are malnourished or at risk of malnutrition and relevant information about nutritional risk should be registered in the patient chart. To facilitate this evaluation, we propose a stratification of nutritional risk in four grades (NG) using three types of simple and validated parameters: preoperative nutritional status (BMI, weight loss, eventually serum albumin), comorbidities and kind of surgery. This stratification can develop a tailored nutritional care for each patient.

Risk factors for bleeding and transfusion during orthotopic liver transplantation.

OBJECTIVE: While orthotopic liver transplantation (OLT) can be associated with haemorrhage, the risk factors for bleeding and transfusion remain difficult to predict. Perioperative transfusion has potentially deleterious side effects and impairs graft and patient survival. Preoperative identification of patients at high risk of bleeding is of clinical interest to manage perioperative transfusion and blood product storage. STUDY DESIGN: Retrospective study. PATIENTS AND METHODS: All OLT conducted between 2004 and 2008 in the University Hospital of Bordeaux were studied. Risk factors for bleeding greater than one blood volume and for massive red blood cell (RBC) transfusion were determined using univariate and multivariate analysis. Thresholds were determined with ROC curve analysis. RESULTS: One hundred and forty-eight transplantations were studied. Preoperative haemoglobin and Child class A were independent protective risk factors for bleeding greater than one blood volume (OR 0.81 [0.67-0.98] and 0.27 [0.10-0.72], respectively). Preoperative Hb was a protective risk factor (OR 0.71 [0.58-0.88]) whereas history of oesophageal varicose bleeding was a risk factor (OR 4.67 [1.45-15.05]) for transfusion of more than eight RBC. CONCLUSION: Risk factors for bleeding and transfusion during OLT identified in this study were of little clinical usefulness so blood products should always be available during the procedure.

[Alzheimer's disease and anaesthesia: potential relationships and clinical implications]. / Maladie d'Alzheimer et anesthésie : relations potentielles et implications cliniques.

Alzheimer's disease is the most common form of dementia. As the aging population increases, Alzheimer's disease is becoming a major concern of Public Health. Many molecular lesions have been detected in Alzheimer's disease, but physiopathology is still poorly understood. If the neurotoxicity of anaesthetics in human remains debatable, perioperative period is certainly a high-risk factor for cognitive impairment, especially in elderly population. Large clinical studies are required to develop new strategies for perioperative management in such patients, including the adjustment of anaesthesia techniques. Before that, information of patient and its relatives and a particular attention for elderly during anaesthesia and perioperative period should be considered.

Aspects épidémiocliniques et évolutives des maladies thromboembolique veineuse à l'Unité de Cardiologie du CHU Antananarivo

Les maladies thromboemboliques veineuses (MTEV) sont graves et mortelles ; elles necessitent une prise en charge d'urgence immediate et multidisciplinaire. Objectifs : Nos objectifs consistent a determiner les aspects epidemio-cliniques; paracliniques et evolutifs de ces maladies; et de rechercher leurs etiologies. Methodes : Il s'agit d'une etude a la fois retrospective et prospective; descriptive et analytique monocentrique realisee a l'USFR de Cardiologie de l'Hopital Universitaire Joseph Raseta Befelatanana; du 1er Janvier 2007 au 31 Decembre 2010. Nous avons recense 43 patients atteints de MTEV. Resultats : 65;12de nos patients ont une thrombose veineuse profonde des membres inferieurs (TVPMI); 32;55une embolie pulmonaire (EP) et 2;33une thrombose veineuse profonde de l'extremite des membres superieurs. Ces pathologies touchent beaucoup plus les femmes de 25 a 55 ans et les hommes a partir de 55 ans. Les principaux signes de decouverte sont la paresthesie; la douleur de la jambe et la douleur de la cuisse pour la TVPMI; et la douleur thoracique; l'hemoptysie et la dyspnee pour l'EP. Les thromboses de la veine surale gauche et de la veine femorale sont les plus frequemment rencontrees au cours de la TVPMI. La thrombose est plus frequemment au niveau de la branche gauche de l'artere pulmonaire pour l'EP; mais peut etre aussi multifocale. Conclusion : Un score de probabilite clinique (score de Wells) moyen ou eleve; avec ou sans positivite du dosage de D Dimeres; est suffisants pour poser le diagnostic. Sous Enoxaparine relaye precocement par Fluindione; 74;41des patients peuvent evoluer de facon favorable

Continuous non-invasive arterial pressure measurement: evaluation of CNAP device during vascular surgery.

OBJECTIVE: Standard non-invasive blood pressure (BP) monitoring is an intermittent, discontinuous procedure. Beat-to-beat BP monitoring requires invasive measurement via an arterial catheter and may be associated with serious complications. The Infinity CNAP SmartPod (Dräger Medical AG & Co. KG, Lübeck, Germany) has recently been proposed for non-invasive continuous beat-to-beat BP measurements. The present study was designed to compare BP obtained with the CNAP and with an invasive method in the operating room. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: Twenty-five patients undergoing major vascular surgery were included. Systolic, mean and diastolic BP were monitored invasively (SAP, MAP and DAP respectively) and not invasively using the CNAP (CNAP-S, CNAP-M and CNAP-D respectively). Measurements were performed intraoperatively every minute during 1 hour. RESULTS: One thousand and five hundred pairs of simultaneous CNAP and invasive BP measurements were obtained and 148 were eliminated. The range of BP measurements was 63-205 mmHg for SAP and 57-187 mmHg for CNAP-S, 38-143 mmHg for MAP and 43-142 mmHg for CNAP-M, 29-126 mmHg for DAP and 33-121 mmHg for CNAP-D. Bias and 95% limit of agreement between CNAP and invasive BP measurements were respectively 7.2 and -17.7 to 32.2 mmHg for SAP, -1.8 and -22.0 to 18.3 mmHg for MAP, and -7.5 and -27.3 to 12.4 mmHg for DAP. The percentage of CNAP measurements with a bias <10% with the arterial line was 69%, 86% and 91% for systolic, diastolic and mean pressures, respectively. CONCLUSION: Despite low accuracy for SAP and DAP measurements, CNAP system seems more accurate for MAP measurement in patients undergoing vascular surgery.

[Fatal haemorrhagic rift valley fever: a case at Madagascar]. / Forme hémorragique grave de la fièvre de la Vallée du Rift: une observation à Madagascar.

Rift valley fever (RVF) is a viral zoonosis that can also infect humans. Haemorrhagic RVF is a severe potentially fatal form of the disease. Although haemorrhagic RVF accounts for only 1% of all infections, death occurs in up to 5% of cases. The purpose of this report is describe a severe case of haemorrhagic RVF observed in a 22-year-old cattle breeder admitted to the intensive care units of the Joseph Raseta Befelatanana University Hospitals in Antananarivo. The disease presented as an infectious syndrome but hemorrhagic manifestations developed early (day 2). They consisted of diffuse haemorrhage events (haemorrhagic vomit, gingival haemorrhage, skin haemorrhage, urinary haemorrhage, and haemorrhage on the venous puncture site). In spite of intensive care, haemorrhagic complications lead to death on day 4 of clinical evolution. Laboratory findings demonstrated alteration in liver function and coagulation disturbances. Multiple organ failure was also observed.