Guidelines on perioperative optimization protocol for the adult patient 2023.

OBJECTIVE: The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS: The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS: Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Postoperative analgesia after surgical repair of distal radius fracture: a randomized comparison between distal peripheral nerve blockade and surgical site infiltration.

BACKGROUND: Pain following open reduction and internal fixation of distal radius fracture (DRF) can be significant. This study compared the intensity of pain up to 48 hours after volar plating for DRF, associated to either an ultrasound guided distal nerve block (DNB) or surgical site infiltration (SSI). METHODS: In this prospective single blind randomized study, 72 patients scheduled for DRF surgery under 1.5% lidocaine axillary block were allocated to receive, at the end of surgery, either an ultrasound-guided median and radial nerves block with ropivacaine 0.375% (DNB) performed by the anesthesiologist or a SSI with the same drug regimen, performed by the surgeon. Primary outcome was the duration between analgesic technique (H0) and pain reappearance (Numerical Rating Scale (NRS 0-10)>3). Secondary outcomes were the quality of analgesia, the quality of sleep, the magnitude of motor blockade, and the patient satisfaction. The study was built on a statistical hypothesis of equivalence. RESULTS: Fifty-nine patients were included in the final per-protocol analysis (DNB=30, SSI=29). Time to reach NRS>3 was (in median [95%CI]) 267 min [155;727] and 164 min [120;181] respectively after DNB and SSI (difference=103 min [-22;594] - rejection of equivalence hypothesis). Pain intensity throughout the 48 hours, quality of sleep, opiate consumption, motor blockade and patient satisfaction was not significantly different between groups. CONCLUSIONS: Although DNB provides a longer analgesia than SSI, both techniques gave comparable level of pain control during the first 48 hours after surgery, without any difference in the incidence of side effects or patient satisfaction.

[Assessment of Teleconsultation for planned orthopaedic surgery]. / Faisabilité d'une téléconsultation d'anesthésie en chirurgie orthopédique programmée.

The COVID-19 pandemic has motivated the development of teleconsultation in anaesthesia. We have conducted a single centre prospective study in patients scheduled for planned orthopaedic surgery during 9 weeks between may and july 2020 to assess its practicability. The quality of the consultation and patients' satisfaction, were evaluated during this period. The teleconsultation was successful in 90% of the patients without the need of attendance to the hospital for assessment before anaesthesia. The process was satisfactory for 97% of these patients. The mean duration was 15 minutes. The support of a third party was required in 46% of patients older than 65 years. The main cause of failure was the poor quality of the connection. Only two patients were cancelled for surgery because they did not understand fasting rule. The teleconsultation is now an integral part of preoperative assessment of patients for anaesthesia with good practicability and reliability.

Cognitive status of patients judged fit for discharge from the post-anaesthesia care unit after general anaesthesia: a randomized comparison between desflurane and propofol.

BACKGROUND: The Aldrete's score is used to determine when a patient can safely leave the Post-Anaesthesia Care Unit (PACU) and be transferred to the surgical ward. The Aldrete score is based on the evaluation of vital signs and consciousness. Cognitive functions according to the anaesthetic strategy at the time the patient is judged fit for discharge from the PACU (Aldrete's score ≥ 9) have not been previously studied. The aim of this trial was to assess the cognitive status of inpatients emerging either from desflurane or propofol anaesthesia, at the time of PACU discharge (Aldrete score ≥ 9). METHODS: Sixty adult patients scheduled for hip or knee arthroplasty under general anaesthesia were randomly allocated to receive either desflurane or propofol anaesthesia. Patients were evaluated the day before surgery using Digit Symbol Substitution Test (DSST), Stroop Color Test and Verbal Learning Test. After surgery, the Aldrete score was checked every 5 min until reaching a score ≥ 9. At this time, the same battery of cognitive tests was applied. Each test was evaluated separately. Cognitive status was reported using a combined Z score pooling together the results of all 3 cognitive tests. RESULTS: Among the 3 tests, only DSST was significantly reduced at Aldrete Score ≥ 9 in the Desflurane group. Combined Z-scores at Aldrete Score ≥ 9 were (in medians [interquartils]): - 0.2 [- 1.2;+ 0.6] and - 0.4 [- 1.1;+ 0.4] for desflurane and propofol groups respectively (P = 0.62). Cognitive dysfunction at Aldrete score ≥ 9 was observed in 3 patients in the Propofol group and in 2 patients in the Desflurane group) (P = 0.93). CONCLUSION: No difference was observed in cognitive status at Aldrete score ≥ 9 between desflurane and propofol anaesthesia. Although approximately 10% of patients still had cognitive dysfunctions, an Aldrete score ≥ 9 was associated with satisfactory cognitive function recovery in the majority of the patients after lower limb arthroplasty surgery under general anaesthesia. TRIAL REGISTRATION: Clinical Trials identifier NTC02036736 .

Systematic Review on the Safety and Tolerability of Transcranial Direct Current Stimulation in Children and Adolescents.

BACKGROUND: Transcranial direct current stimulation (tDCS) is a safe, tolerable, and acceptable technique in adults. However, there is limited evidence for its safety in youth. Although limited, there are a handful of important empirical articles that have evaluated safety and tolerability outcomes in youth. However, a synthesis of pediatric safety studies is not currently available. OBJECTIVE: To synthesize objective evidence regarding the safety and tolerability of pediatric tDCS based on the current state of the literature. METHODS: Our search and report used PRISMA guidelines. Our method systematically examined investigations purposefully designed to evaluate the safety, tolerability, and acceptability of tDCS in healthy and atypical youth that were submitted to three databases, from the beginning of the database to November 2019. Safety considerations were evaluated by studies utilizing neuroimaging, physiological changes, performance on tasks, and by analyzing reported and objective side effects; tolerability via rate of adverse events; and acceptability via rate of dropouts. RESULTS: We report on 203 sham sessions, 864 active sessions up to 2 mA, and 303 active hours of stimulation in 156 children. A total of 4.4% of the active sessions were in neurotypical controls, with the other 95.6% in clinical subjects. CONCLUSION: In spite of the fact that the current evidence is sporadic and scarce, the presently reviewed literature provides support for the safety, tolerability, and acceptability, of tDCS in youth for 1-20 sessions of 20 min up to 2 mA. Future pediatric tDCS research is encouraged.

Surgical Revascularization With Cardiopulmonary Bypass on a Patient With Severe COVID-19.

The coronavirus disease 2019 (COVID-19) may lead to an acute respiratory distress syndrome by an inappropriate cytokine response and may predispose to a prothrombotic state through multiple pathways. Both can complicate the management of cardiac surgery with cardiopulmonary bypass, which is known to activate the hemostatic system and to exacerbate systemic inflammatory response. Little is known about the impact of cardiac surgery with cardiopulmonary bypass on viral pneumonia, particularly with the new coronavirus. In this article, we describe the case of a diabetic patient with COVID-19 and a concomitant 3-vessel disease with a formal indication for surgical revascularization, who unexpectedly presented with a high heparin resistance during cardiopulmonary bypass. Emphasis is placed on the importance of multidisciplinary team discussions before surgery, on the thorough preoperative assessment, and on the perioperative management, particularly regarding mechanical ventilation and anticoagulation.

HELP-VDL: study protocol for a multicentre, open, randomised, controlled clinical trial comparing the use of the head-elevated laryngoscopy position and the use of a videolaryngoscope to facilitate orotracheal intubation in a patient population without predictable difficulty of intubation.

INTRODUCTION: Tracheal intubation remains an everyday challenge for anaesthesiologists, even in patients without suspected difficult airways. The ideal positioning of the patient's head (flat, raised a few centimetres on a cushion in the sniffing position (SP), or raised to achieve horizontal alignment between the external acoustic meatus and the sternal angle) and the use of videolaryngoscopy remain controversial. This trial aims to compare the efficacy for orotracheal intubation of the SP or the head-elevated laryngoscopy position (HELP), which has been shown to improve laryngeal visualization and the intubation condition particularly in obese patients, in combination with a McGrath Mac videolaryngoscope whose video screen is either on or off (Video or NoVideo). METHODS AND ANALYSIS: The HELP-VDL factorial trial is a prospective, randomised, parallel, multicentre, open study of 240 adult patients undergoing tracheal intubation under general anaesthesia. Patients will be allocated into four groups: SP-NoVideo, HELP-NoVideo, SP-Video and HELP-Video. The primary outcome is the proportion of orotracheal intubations that requires the assistance of a nurse anaesthetist. The secondary outcomes include the intubation duration, the first intubation success rate, the quality of visualisation of the glottis, the glottis visualisation score, adjunctive manoeuvres and alternative techniques used, the occurrence of oesophageal intubation, failure of tracheal intubation, the incidence of arterial oxygen desaturation, the perception of a difficult intubation, the score on the Intubation Difficulty Scale, cooperation among the members of the anaesthesia team, the evolution of vital signs and the frequency and severity of intubation complications. Data will be analysed on the intention-to-treat principle and a per-protocol basis. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Ethical Committee Ile de France V (Paris, France). Participant recruitment began on 3 July 2019. The results will be submitted for publication in peer-reviewed journals.Trial registration numberNCT03987009; Pre-results.

Evaluation of Cardiac Index and Extravascular Lung Water After Single-Lung Transplantation Using the Transpulmonary Thermodilution Technique by the PiCCO2 Device.

OBJECTIVES: First evaluation of the transpulmonary thermodilution technique by the PiCCO2 device to assess cardiac index and pulmonary edema during the postoperative course after single-lung transplantation. DESIGN: Prospective observational study. SETTINGS: Intensive care unit, university hospital (single center). PARTICIPANTS: Single-lung transplant patients. INTERVENTIONS: The authors compared cardiac index measured by PiCCO2 and pulmonary artery catheter and assessed pulmonary edema using extravascular lung water index and pulmonary vascular permeability index measured by PiCCO2. MEASUREMENTS AND MAIN RESULTS: A Bland-Altman method was used to compare cardiac index measured by PiCCO2 and pulmonary artery catheter. Extravascular lung water index and pulmonary vascular permeability index were compared according to the PaO2/FiO2 ratio with a threshold value of 150 mmHg. Ten single-lung transplant patients were included. Cardiac index measured by PiCCO2 and pulmonary artery catheter were 3.3 L/min/m2 (2.9-3.6) and 2.5 L/min/m2 (2.2-3.0). Bias for cardiac index was 0.71 L/min/m2 (-0.03; 1.44) and limit of agreements were -0.03 and 1.44 L/min/m2. Extravascular lung water index was 12 mL/kg (11-16) and pulmonary vascular permeability index was 2.3 (2.0-3.1), consistent with pulmonary edema. Extravascular lung water index was higher in the group of PaO2/FiO2 ratio ≤150 mmHg compared with the group of PaO2/FiO2 ratio >150 mmHg (17 v 12 mL/kg, p = 0.04), whereas pulmonary vascular permeability index only tended to be higher (3.1 v 2.1, p = 0.06). CONCLUSION: PiCCO2 device systematically overestimated cardiac index compared with pulmonary artery catheter. However, it might be useful to assess pulmonary edema in acute respiratory failure after single-lung transplantation.

Neutrophil expression of glucocorticoid-induced leucine zipper (GILZ) anti-inflammatory protein is associated with acute respiratory distress syndrome severity.

BACKGROUND: Glucocorticoid-induced leucine zipper (GILZ) is a potent anti-inflammatory protein involved in neutrophil apoptosis and the resolution of inflammation. Given the numerous pathophysiologic roles of neutrophils in the acute respiratory distress syndrome (ARDS), we postulated that neutrophil GILZ expression might be induced during ARDS, to modulate the inflammatory process and participate in lung repair. METHODS: This single-center, prospective, observational cohort study took place in the surgical intensive care unit of Bichat Hospital (Paris, France) and involved 17 ARDS patients meeting the Berlin criteria at inclusion, and 14 ventilated controls without ARDS. Serial blood samples were obtained every 2 days until extubation or death (from 1 to 9 samples per patient). GILZ protein and gene expression was quantified in blood neutrophils, along with markers of inflammation (CRP, extracellular DNA) or its resolution (Annexin A1). RESULTS: Neutrophil GILZ expression was detected at the transcriptional and/or translational level in 9/17 ARDS patients (in particular 7/10 severe ARDS) and in 2/14 ventilated controls. The highest mRNA levels were observed in the most severely ill patients (p < 0.028). GILZ was expressed in about ¾ of the corticosteroid-treated patients and its expression could also occur independently of corticosteroids, suggesting that inflammatory signals may also induce neutrophil GILZ expression in vivo. CONCLUSIONS: In this pilot study, we show for the first time that blood neutrophils from patients with ARDS can express GILZ, in keeping with an anti-inflammatory and regulatory endogenous role of GILZ in humans. Contrary to some markers of inflammation or its resolution, the levels of gilz gene expression were related to ARDS severity.

Does IV Iron Induce Plasma Oxidative Stress in Critically Ill Patients? A Comparison With Healthy Volunteers.

OBJECTIVE: To compare the oxidative stress induced by IV iron infusion in critically ill patients and in healthy volunteers. DESIGN: Multicenter, interventional study. SETTING: Two ICUs and one clinical research center. SUBJECTS: Anemic critically ill patients treated with IV iron and healthy volunteers. INTERVENTIONS: IV infusion of 100 mg of iron sucrose. MEASUREMENTS AND MAIN RESULTS: Thirty-eight anemic patients (hemoglobin, median [interquartile range] = 8.4 g/dL [7.7-9.2]) (men, 25 [66%]; aged 68 yr [48-77]; Simplified Acute Physiology Score II, 48.5 [39-59]) and 39 healthy volunteers (men, 18 [46%]; aged 42.1 yr [29-50]) were included. Blood samples were drawn before (H0) and 2, 6, and 24 hours (H2, H6, and H24) after a 60-minute iron infusion for the determination of nontransferrin bound iron, markers of lipid peroxidation-8α-isoprostanes, protein oxidation-advanced oxidized protein product, and glutathione reduced/oxidized. Iron infusion had no effect on hemodynamic parameter in patients and volunteers. At baseline, patients had much higher interleukin-6, C-reactive protein, and hepcidin levels. 8α-isoprostanes was also higher in patients at baseline (8.5 pmol/L [6.5-12.9] vs 4.6 pmol/L [3.5-5.5]), but the area under the curve above baseline from H0 to H6 was not different (p = 0.38). Neither was it for advanced oxidized protein product and nontransferrin bound iron. The area under the curve above baseline from H0 to H6 (glutathione reduced/oxidized) was lower in volunteers (p = 0.009). Eight patients had a second set of dosages (after the fourth iron infusion), showing higher increase in 8α-isoprostanes. CONCLUSIONS: In our observation, IV iron infusion does not induce more nontransferrin bound iron, lipid, or protein oxidation in patients compared with volunteers, despite higher inflammation, oxidative stress, and hepcidin levels and lower antioxidant at baseline. In contrary, iron induces a greater decrease in antioxidant, compatible with higher oxidative stress in volunteers than in critically ill patients.

Dynamic changes of microbial flora and therapeutic consequences in persistent peritonitis.

INTRODUCTION: Persistent peritonitis is a frequent complication of secondary peritonitis requiring additional reoperations and antibiotic therapy. This situation raises specific concerns due to microbiological changes in peritoneal samples, especially the emergence of multidrug-resistant (MDR) strains. Although this complication has been extensively studied, the rate and dynamics of MDR strains have rarely been analysed. METHODS: We compared the clinical, microbiological and therapeutic data of consecutive ICU patients admitted for postoperative peritonitis either without subsequent reoperation (n = 122) or who underwent repeated surgery for persistent peritonitis with positive peritoneal fluid cultures (n = 98). Data collected on index surgery for the treatment of postoperative peritonitis were compared between these two groups. In the patients with persistent peritonitis, the data obtained at the first, second and third reoperations were compared with those of index surgery. Risk factors for emergence of MDR strains were assessed. RESULTS: At the time of index surgery, no parameters were able to differentiate patients with or without persistent peritonitis except for increased severity and high proportions of fungal isolates in the persistent peritonitis group. The mean time to reoperation was similar from the first to the third reoperation (range: 5 to 6 days). Septic shock was the main clinical expression of persistent peritonitis. A progressive shift of peritoneal flora was observed with the number of reoperations, comprising extinction of susceptible strains and emergence of 85 MDR strains. The proportion of patients harbouring MDR strains increased from 41% at index surgery, to 49% at the first, 54% at the second (P = 0.037) and 76% at the third reoperation (P = 0.003 versus index surgery). In multivariate analysis, the only risk factor for emergence of MDR strains was time to reoperation (OR 1.19 per day, 95%CI (1.08 to 1.33), P = 0.0006). CONCLUSIONS: Initial severity, presence of Candida in surgical samples and inadequate source control are the major risk factors for persistent peritonitis. Emergence of MDR bacteria is frequent and increases progressively with the number of reoperations. No link was demonstrated between emergence of MDR strains and antibiotic regimens, while source control and its timing appeared to be major determinants of emergence of MDR strains.

Diagnosis and management of the postoperative surgical and medical complications of bariatric surgery.

Perioperative complications following bariatric surgery (BS) have been poorly analysed and their management is not clearly assessed. The associated frequency of ICU admission is difficult to estimate. Among surgical complications, digestive perforations are the most frequent. The most common postoperative complications of sleeve gastrectomy are fistulas, but bleeding on the stapling line is also commonly reported. Complication rates are higher after Roux-en-Y gastric bypass, mainly due to anastomotic leaks. Medical complications are mainly thromboembolic or respiratory complications. All these surgical and medical complications are not easily detected; clinical signs can be atypical or insidious, often resulting in delayed management. Respiratory signs can be predominant and lead erroneously to pulmonary or thromboembolic diseases. Diagnostic criteria are based on minor clinical signs, tachycardia being probably the most frequent one. Lately, complications are revealed by haemodynamic instability, respiratory failure or renal dysfunction and radiographic findings. Management decision according to these abnormal signs is based on a combined multidisciplanary approach including surgical and/or endoscopic procedures and medical care, depending on the nature and severity of the surgical complication. Medical management is based on supportive ICU care of organ dysfunctions, curative anticoagulation if required, nutritional support, and appropriate anti-infective therapy. Pharmacological data are limited in morbidly obese patients and the appropriate doses are debated, especially for anti-infective agents. Complicated BS cases have a poor outcome, probably largely related to delayed diagnosis and reoperation.

Echocardiography to predict tolerance to negative fluid balance in acute respiratory distress syndrome/acute lung injury.

PURPOSE: In acute respiratory distress syndrome (ARDS) and acute lung injury (ALI), a conservative fluid management strategy improves lung function but could jeopardize extrapulmonary organ perfusion. The objective was to evaluate the diagnostic accuracy of echocardiography to predict tolerance of negative fluid balance (NFB) in patients with ARDS/ALI. MATERIALS AND METHODS: A prospective and observational study in an adult intensive care unit of a university hospital was conducted. All hemodynamically stable patients with ARDS/ALI were included. Echocardiography was performed before NFB and again after 24 hours. Tolerance of NFB was evaluated by the presence of hypotension, acute kidney injury, or need for fluid expansion. The 2 patient groups (tolerating and not tolerating NFB) were compared. RESULTS: Forty-five patients were included. Median age (Q1-Q3) was 58 (52-66) years, and the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen was 205 (163-258) mm Hg. Negative fluid balance was 1950 (1200-2200) mL within 24 hours in the tolerant group. Complications of NFB were observed in 35% cases. After univariate and multivariate logistic regression analyzes, 2 criteria was independently associates with poor tolerance: mitral inflow E wave to early diastolic mitral annulus velocities ratio (E/Ea ratio; odds ratio, 2.02 [1.02-4.02]; P = .04) and weight gain (odds ratio, 1.2 [1.03-1.4]; P = .02). The area under receiver operating characteristic curves was 0.74 for E/Ea and 0.77 for weight gain. CONCLUSIONS: The ratio of E/Ea accurately predicted tolerance of NFB in patients with ARDS/ALI.

Clinical features and outcome of postoperative peritonitis following bariatric surgery.

BACKGROUND: We assessed the clinical features and outcome of morbidly obese patients admitted to the intensive care unit (ICU) for management of postoperative peritonitis (POP) following bariatric surgery (BS). METHODS: In a prospective, observational, surgical ICU cohort, we compared the clinical features, empiric antibiotic therapy, and prognosis of BS patients with those developing POP after conventional surgery (cPOP). RESULTS: Overall, 49 BS patients were compared to 134 cPOP patients. BS patients were younger (45 ± 10 versus 63 ± 16 years; p < 0.0001), had lower rates of fatal underlying disease (39 vs. 64%; p = 0.002), and the same SOFA score at the time of reoperation (8 ± 4 vs 8 ± 3; p = 0.8) as the cPOP patients. BS patients had higher proportions of Gram-positive cocci (48 vs. 35 %; p = 0.007) and lower proportions of Gram-negative bacilli (33 vs. 44%; p = 0.03), anaerobes (4 vs. 10%; p = 0.04), and multidrug-resistant strains (20 vs. 40%; p = 0.01). Despite higher rates of adequate empiric antibiotic therapy (82 vs. 64%; p = 0.024) and high de-escalation rates (67% in BS cases and 51% in cPOP cases; p = 0.06), BS patients had similar reoperation rates (53 vs. 44%; p = 0.278) and similar mortality rates (24 vs. 32%; p = 0.32) to cPOP patients. In multivariate analysis, none of the risk factors for death were related to BS. CONCLUSIONS: The severity of POP in BS patients resulted in high mortality rates, similar to the results observed in cPOP. Usual empiric antibiotic therapy protocols should be applied to target multidrug-resistant microorganisms, but de-escalation can be performed in most cases.

Afa/Dr diffusely adhering Escherichia coli strain C1845 induces neutrophil extracellular traps that kill bacteria and damage human enterocyte-like cells.

We recently documented the neutrophil response to enterovirulent diffusely adherent Escherichia coli expressing Afa/Dr fimbriae (Afa/Dr DAEC), using the human myeloid cell line PLB-985 differentiated into fully mature neutrophils. Upon activation, particularly during infections, neutrophils release neutrophil extracellular traps (NETs), composed of a nuclear DNA backbone associated with antimicrobial peptides, histones, and proteases, which entrap and kill pathogens. Here, using fluorescence microscopy and field emission scanning electron microscopy, we observed NET production by PLB-985 cells infected with the Afa/Dr wild-type (WT) E. coli strain C1845. We found that these NETs were able to capture, immobilize, and kill WT C1845 bacteria. We also developed a coculture model of human enterocyte-like Caco-2/TC7 cells and PLB-985 cells previously treated with WT C1845 and found, for the first time, that the F-actin cytoskeleton of enterocyte-like cells is damaged in the presence of bacterium-induced NETs and that this deleterious effect is prevented by inhibition of protease release. These findings provide new insights into the neutrophil response to bacterial infection via the production of bactericidal NETs and suggest that NETs may damage the intestinal epithelium, particularly in situations such as inflammatory bowel diseases.

Aortic rupture due to pneumococcal infection in aortoiliac stents.

We report a rare case of pneumococcal aortitis secondary to endovascular bare-metal stent infection. The patient was a 70-year-old man presenting with back pain 1 year after aortoiliac implantation of bare-metal kissing stents. Final diagnosis was microbial aortitis due to Streptococcus pneumoniae involving the stents that resulted in a contained aortic rupture requiring urgent surgical treatment. Emergency extra-anatomic revascularization, excision of the infected tissues, and appropriate antibiotic therapy led to a favorable outcome. A high index of suspicion is required in such a situation because the mortality rate is very high in the absence of appropriate treatment.

Abdominal compartment syndrome due to extracorporeal membrane oxygenation in adults.

Extracorporeal membrane oxygenation (ECMO) improves the outcome of refractory cardiogenic shock. Few studies in adult populations have specifically addressed the complications of ECMO. Abdominal compartment syndrome (ACS) has been previously described in the pediatric literature, but it has never been directly attributed to ECMO alone. The authors describe two cases of ACS directly induced by venoarterial ECMO. In one case, decompressive laparotomy restored an adequate hemodynamic status. The authors hypothesize that ECMO contributed to ACS by inducing massive fluid overload and subsequent tense ascites. In conclusion, when ECMO dysfunction or hemodynamic impairment occurs, ACS should be considered and a decompressive laparotomy should be performed.

Preoperative statin treatment is associated with reduced postoperative mortality after isolated cardiac valve surgery in high-risk patients.

OBJECTIVE: The aim of the present study was to assess the influence of preoperative statin therapy on postoperative mortality in high-risk patients after isolated valve surgery. DESIGN: An observational cohort study. SETTING: A 1,200-bed university hospital. PARTICIPANTS: All consecutive patients undergoing isolated nonemergent valve surgery with cardiopulmonary bypass between November 2005 and December 2007 were included. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: During the period, 772 consecutive patients underwent nonemergent isolated valve surgery. Among them, 430 were high cardiovascular risk (defined by patients with 2 or more cardiovascular risk factors). In the high-risk cardiovascular patients, statin pretreatment was administered in 222 patients (52%). In multivariate analysis, after adjustment with a propensity score analysis, preoperative statin therapy was associated with a significant reduction of postoperative mortality in patients with high risk (odds ratio = 0.41; 95% confidence interval, 0.17-0.97; p = 0.04). Low left ventricular ejection fraction and elevated pulmonary artery pressure also were independently associated with increased postoperative mortality. By contrast, in the low-risk patient group, few patients received preoperative statin therapy (7%). CONCLUSIONS: This study suggests that preoperative statin therapy may have a potential beneficial effect on postoperative mortality after isolated cardiac valve surgery in high-risk cardiovascular patients.

Pharmacokinetics of antibiotics or antifungal drugs in intensive care units.

Intensive care unit (ICU) patients present several unusual pharmacokinetic (PK) characteristics compared with less seriously ill patients, including increased distribution volume and variable clearance. Interpatient PK variability is often considerable and can produce a wide range of values for PK parameters and major differences in drug exposure. These analyses have led to the development of simulation techniques and population PK models to assess dosing regimens in specific patient subsets. Plasma concentrations may frequently overestimate target-site concentrations and therefore clinical efficacy. The unbound drug concentration at the infection site should be preferred. Although renal replacement therapy techniques are commonly used in ICU patients, data concerning antibiotic dosing in this setting remain limited. Administration of antibacterial agents by continuous infusion is becoming a common technique to avoid undesirable high peak concentrations and low trough concentrations and to optimize PK-pharmacodynamic indices.