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A round table, organized by the French Society of Perfusion (Sofraperf) at the French national congress on extracorporeal circulations (Perfusion 2013), was attended by perfusionists, anaesthesiologists, intensivists and surgeons around the theme of respiratory veno-venous support and veno-arterial circulatory support with extracorporeal oxygenation in intensive care units. The debate was conducted in a participatory manner by bi-directional questions-answers session between moderators and assistance. The authors report management of this type of therapy that is not perfectly homogeneous, supported on literature data. Cannulae, cannulation, circuit, oxygenator, anticoagulation, control, surveillance, weaning are subject to paragraphs with defined entry whose contents are mutually enriching., (Copyright © 2014. Published by Elsevier SAS.)

Objectives: To review the practical aspects of temporary epicardial pacing following open heart surgery., Methods: Review of articles published in English or French within the last five years and investigating temporary epicardial pacing (indications, pacing modes, epicardial wires and temporary generators). The studies were extracted from the databases ScienceDirect and Pubmed., Results: Temporary epicardial pacing is used to treat severe conduction and/or rhythm disorders, but also to improve hemodynamics by optimizing selected temporary pacing settings. Temporary epicardial pacing consists in choosing the most suitable pacing mode according to the situation (surgery, patient, conduction and/or rhythm abnormalities) and setting its parameters that ensure : i) optimal pacemaker functioning; ii) epicardial electrodes longevity; iii) the most favorable hemodynamic profiles. Management of temporary pacing settings and their regular adjustment, at least daily and based on thresholds, are part of good clinical practices. Nevertheless, the French literature lacks official recommendations for temporary epicardial pacing., Conclusion: Temporary epicardial pacing following cardiac surgery is a simple method, more effective than transcutaneous pacing and easier to implement than transvenous pacing. Its practical management should be known by all physicians (anesthetists, cardiac surgeons) as well as paramedical personnel in order to avoid the risks of suboptimal functioning. A good practice protocol is proposed at the end of the manuscript., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Cardiac diseases are the second cause of non-obstetrical death during pregnancy in France. Bicuspid aortic valve is the most frequent congenital cardiac disease but its characteristics are little known. We report two consecutive cases of pregnant patients with aortic bicuspidy, one with a severe aortic stenosis and one with a severe dilatation of the ascending aorta. We describe the anaesthetic management of delivery for these two cases and summarize the current recommendations for management of this condition during pregnancy., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Alpha-2 adrenergic agonists ("alpha-2 agonists") present multiple pharmacodynamic effects: rousable sedation, decreased incidence of delirium in the setting of critical care, preservation of respiratory drive, decreased whole body oxygen consumption, decreased systemic and pulmonary arterial impedance, improved left ventricular systolic and diastolic function, preserved vascular reactivity to exogenous catecholamines, preserved vasomotor baroreflex with lowered set point, preserved kidney function, decreased protein catabolism. These pharmacodynamic effects explain the interest for these drugs in the critical care setting. However, their exact role for sedation in critically ill-patients remains open for further studies. Given the few double-blind randomized multicentric trials available, the present non exhaustive analysis of the literature aims at presenting the utilization of alpha-2 agonists as potential first-line sedative agents, in the critical care setting. Suggestions regarding the use of alpha-2 agonists as sedatives are detailed., (Copyright © 2012 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

This article provides a synthesis of physiology and pathophysiology of the cardiovascular system and briefly presents the principles of regulation at the level of the whole organism and regional circulations. Decision algorithms, based on knowledge of physiology and pathophysiology are proposed. Their goal is to contribute to the improvement of cardiopulmonary bypass practice., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Recently, three case reports have suggested the possible efficacy of sugammadex in anaphylactic shock refractory to conventional treatment induced by rocuronium. We report a new case of severe anaphylactic reaction to rocuronium treated with sugammadex. After 18 minutes of conventional treatment because of persistent cardiocirculatory failure and bronchospasm, a bolus of 2000 mg (18 mg/kg) of sugammadex was injected. This was associated with rapid correction of arterial hypotension and bronchoconstriction. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are unknown but it is important to know that refractory anaphylactic shock to rocuronium can be potentially corrected with sugammadex., (Copyright © 2011 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Objective: To describe the perioperative management, from the point of view of the anesthesia-intensive care unit specialist, of patients with aortic stenosis who undergo transcatheter aortic valve implantation (femoral or apical TAVI)., Data Source: The PubMed database (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) was queried, using the following keywords: aortic stenosis, transcatheter aortic valve implantation TAVI, outcome, complications, anesthesia., Data Synthesis: TAVI is performed in patients suffering from aortic stenosis and presenting with numerous comorbidities, high-predicted perioperative mortality and/or contraindications to conventional cardiac surgery. TAVI is performed either by percutaneous transfemoral or transapical puncture of the left ventricle (LV) apex. These patients are older, have more comorbidities than those undergoing aortic valve replacement surgery and perioperative mortality predicted by risk scores is higher. While transapical TAVI is performed with general anaesthesia, transfemoral TAVI can be performed with either general or locoregional anaesthesia and/or sedation. The choice of the anaesthetic technique for transfemoral TAVI depends on the patient's medical history, the technique chosen for valve implantation, the type of monitoring and the anticipated hemodynamic problems. The incidence of complications following TAVI is high, some are common to surgical aortic valve replacement, and others are specific to this technique. Because of the prevalence of comorbidities, the hemodynamic-specific constraints of this technique and the incidence of complications, anaesthetic and perioperative management (evaluation, anaesthetic technique, monitoring, post-surgery care) requires the same level of expertise as in cardiac surgery anaesthesia., Conclusion: TAVI expands treatment options for patients with aortic valve stenosis. The anaesthesia team must be involved in the care of these patients with the same level of expertise and care as in heart surgery on critical patients., (2011 Elsevier Masson SAS. All rights reserved.)

Objective: Sugammadex reverses neuromuscular blockade by chemical encapsulation of nondepolarizing neuromuscular blocking drugs (rocuronium and vecuronium). The imprint of this new molecule has recently been supplemented with a section on haemostasis notifying a longer clotting time without documented clinical consequences. This has resulted in recommendations on the use of sugammadex in the presence of coagulation disorders (pharmacologically-induced or not). The objective of this study was to analyze the experience gathered with this molecule on clinically-evaluated bleeding. No study on this subject is currently available., Methods: This is a retrospective study over 1 year between August 2009 and August 2010. All patients with laparotomies for cancer surgery requiring suction drains were included. Patients were allocated to groups according to the type of reversal (without sugammadex versus sugammadex 2 or 4 mg/kg). The endpoint was clinically-evaluated postoperative bleeding (reoperation for haemostasis, blood-stained laparotomy dressings in the post-anaesthesia care unit [PACU], cumulative volume collected in suction drains upon arrival in PACU and then after 2 hours and the next morning at 6a.m)., Results: One hundred and ninety-three patients were included in three groups, 78 in the group "without sugammadex", 95 in "sugammadex 2mg/kg" and 20 in "sugammadex 4 mg/kg". There were no reoperations for haemostasis. The comparison among different groups for the endpoint of bleeding showed no significant difference., Conclusion: In this retrospective study performed in patients at high risk of postoperative bleeding, sugammadex at doses of 2 and 4 mg/kg was not associated with increased bleeding. This study, the first in this field, suggests that future prospective investigations should target patients receiving 4 or 16 mg/kg of sugammadex and/or with documented preoperative abnormal coagulations tests., (2011 Elsevier Masson SAS. All rights reserved.)

Objectives: The field of new cardiac biomarkers has triggered physicians' enthusiasm because of their potential diagnostic and prognostic values for routine clinical practice in the surgical setting. The objective of the present article is to review the role of new cardiac biomarkers and their potential additive clinical value in predicting short- and long-term risk following cardiac and non-cardiac surgery., Data Sources: A PubMed(®) database research in English and French languages published until June 2010. Keywords were cardiac biomarkers, troponins, cardiac troponin I (cTnI), natriuretic peptides, B-type natriuretic peptide (BNP), C-reactive protein (CRP), multiple markers approach, risk stratification, clinical risk scores., Data Synthesis: Numerous publications deal with the diagnostic and prognostic values of new cardiac biomarkers in cardiac and non-cardiac surgical settings and provide an increasing evidence of their interest, validating different hierarchical steps which are mandatory before recommending a wide use of biomarkers for routine practice. Even if the first studies demonstrating an additional prognostic value of serum postoperative cTnI and/or preoperative BNP when compared with clinical predictive models are now available, we still lack data concerning an actual positive impact of new biomarkers measurements on clinical decision making or practice, as well as patient care and outcome., Conclusions: While use of new cardiac biomarkers in the perioperative period appears to be a simple and objective tool for risk stratification at the bedside, we still need to remain cautious concerning their additional clinical value on existing predictive models for routine practice., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

The vagal nerve stimulation is approved for medically refractory epilepsy and major depression. We report the perioperative management of an epileptic patient with this indwelling device. This observation summarizes the physiologic implications and the specific anaesthetic considerations for procedures with this pre-existing device., (2010 Elsevier Masson SAS. All rights reserved.)

Background: Hyperthermic intraperitoneal chemoperfusion (HIPEC) is an innovative treatment of the peritoneal carcinomatosis with potential iatrogenicity. This observational study was designed to improve our understanding of HIPEC's impact on the renal and respiratory functions, on temperature, blood cells counts, body fluids/electrolytes and acid-base balance., Methods: We retrospectively analyzed the perioperative care of 20 patients that underwent HIPEC with oxaliplatin (n=19) and mitomycin C (n=1). The abdominal cavity was filled with the peritoneal dialysis fluid with dextrose 5%: volume of 2L/m(2). Follow-up for the study was stopped on postoperative day 7., Results: The main changes were appearing just after the HIPEC procedure: increased diuresis, lactic acidosis, hyponatremia and hyperglycaemia (despite aggressive intravenous insulin therapy). In our series, there was no renal failure or impact on blood cells counts until the 7(th) day, neither some changes on the arterial blood gases., Conclusion: Hyperglycemia might explain increased diuresis of lactic acidosis and the rapid installation of hyponatremia. Taken together, these results suggest that glycemic control must be improved in order to avoid the other metabolic disturbances., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Introduction: Cardiopulmonary bypass (CPB) is a medical act that can be performed by nurses as long as they are constantly supervised by a physician. No initial formalized training course is required. The personal responsibilities of nurses and physicians about CPB have not been defined., Objectives: The purpose of this study was: to list perfusionists; to evaluate the training of perfusionists; to determine which physicians are considered as in charge during actions performed by paramedics, as well as their qualification; to point out the changes since 1997., Type of Study: Professional practice assessment., Methods: A questionnaire was sent to all perfusionists in activity in France., Results: There were 71% of replies. We found an aging of perfusionists (median 49 years vs. 40 years in 1997), a fall in the proportion of trained physicians (13% of perfusionists had a training course in adequacy with professional guidelines, 25% of perfusionists said they worked with a physician who could intervene at all time, and 61% declared only one physician was in charge). There is no CPB referent in 26% of perfusion units., Conclusion: An urgent need appears to define the respective responsibilities of medical and paramedical perfusion staff, especially as this technique spreads out of the conventional cardiac surgery operating theatres., (Copyright 2010 Elsevier Masson SAS. All rights reserved.)

Biological biomarkers are not a novelty in medicine but the number of prescriptions for biomarkers has increased steadily in recent years and now represents a global market of several billion dollars. The goals of this article, initially defined during the 2008 Congress of the French Society of Anaesthesia and Intensive Care when the prize of the best manuscript submitted to the Annales françaises d'anesthésie et de réanimation was awarded, are the following: (i) propose a conceptual framework for use of biomarkers in general; (ii) provide several methodologic details that could help the research and clinical community to better interpret both the results of the literature and their own data; (iii) briefly discuss statistical constraints related to the use of biomarkers; (iv) attempt to analyze the way statistical constraints must modify clinical reasoning related to biomarkers.

Introduction: Several surveys demonstrated that cardiopulmonary bypass (CPB) is associated with incidents that negatively affect the outcome of cardiac surgery., Objectives: In 2004, the French "Haute Autorité de santé" (an independent public scientific authority) and the French "College of Perfusion" issued recommendations concerning safety and monitoring devices for CPB. The aims of the present study were to: 1) investigate the difference between the recommendations and the clinical practice of CPB shortly after publication of the recommendations; 1) investigate the type and rate of perfusion incidents and their outcome., Study Design: Retrospective survey., Methods: A 62 items questionnaire was sent to all 66 centres performing cardiac surgery in France., Results: Fifty-seven centres totalling 34,496 CPB procedures (response rate 86%) returned the questionnaire. There was a wide difference between the recommendations and the reported use of safety and monitoring devices. An incident was reported for every 198 CPB procedures with death occurring 1:4,864 and permanent sequelae 1:11,349 procedures respectively (permanent injury or death 1:3,220 procedures). The most frequent perfusion incidents were adverse effects to protamine (1:1,702), dissection at the arterial canulation site (1:1,792) and coagulation of the circuit (1: 4,864)., Conclusion: This survey demonstrates that an important effort must be made in order to fill the gap between the recommendations and clinical use of monitoring and safety devices. The analysis of CPB-related incidents suggests that, with the exception of protamine adverse effects, the majority of deaths and severe permanent injuries could probably be avoided by improved use of the monitoring and safety devices.

Care and therapy of patients experiencing an anaphylactic reaction should be known by the physicians working in the emergency medical unit or in pre-hospital care. The epidemiology of these reactions varies according to the countries. The main aetiologies are due to food, hymenoptera or drugs. The clinical scale proposed by Ring and Messmer aims to classify the reactions in 4 grades according to their severity and is useful to stratify therapy. According to the grade of the reaction, the drug of choice for the treatment of anaphylaxis is epinephrine associated to vascular expansion. Anaphylaxis during pregnancy is described. Patients who experienced an immediate hypersensitivity reaction should undergo an allergological investigation to prove the immune mechanism and to identify the culprit allergen. Reporting to the Drug Safety Monitoring Authorities when a drug is implicated should not be forgotten.

Objectives: Ageing of the surgical population and the evolution in anaesthetic techniques have led the Club d'anesthésie-réanimation et techniques en chirurgie cardiaque (ARTECC) to conduct a survey among French cardiac surgery centers. The aim was to profile patient population undergoing cardiac surgery and perioperative techniques employed., Study: National prospective study including all adult patients undergoing cardiac surgery on January 23rd, 24th and 25th, 2001. Data were collected during the first 48 postoperative hours., Material and Methods: Seven referent centers drafted a record form. Sixty-one centers sent back 425 patient forms, 399 were analyzed. The following were statistically studied: type of surgery, patient characteristics, preoperative treatment, monitoring, anaesthesia, cardio-pulmonary bypass (CPB) characteristics, duration of mechanical ventilation, length of stay in intensive care unit, postoperative complications., Results: Patient mean age was 64.3 +/- 13.3 years. Patients over 80-year-old represented 2.5% of the population. Beating heart coronary aortic bypass grafts (13% surgery) and preoperative transoesophagal echography were not frequent. Propofol and sufentanil were the main anaesthetic agents used. There was a marked trend for fast-track procedures., Conclusions: The ARTECC study pointed out some reserve in practices and that the impact of new techniques seems limited. Regular use of studies of that kind will provide an effective tool to compare national practices.

We report a case of Budd-Chiari syndrome revealing a polycythemia vera and complicated by heparin-induced thrombocytopenia. A surgical porto-caval shunt was inserted with danaparoid as anticoagulant during the peri-operative period. The doses of danaparoid were as follows: a continuous intravenous infusion of 200 U/h with a target between 0.5 et 0.8 U/ml antifactor Xa activity during the preoperative period, followed by 100 U/h with a target of 0.3 U/ml during the peroperative period; an increase in doses of danaparoid to 150 and 200 U/h with a target above 0.5 U/ml was used during the postoperative period. This case report is a rare situation of hypercoagulable state, in a surgical context, treated with danaparoid.

Objectives: The number of cardiac transplantation procedures does not increase because of the lack of donor hearts despite an increase in the number of brain-dead organ donors. The criteria used to select a donor heart are not formally standardized. The aim of the present study was to analyze the criteria that contribute to the selection of a donor heart., Type of Study: Descriptive, retrospective study., Patients and Method: Clinical parameters, the initial causes that lead to brain death, maximum doses of catecholamines, several biochemical markers of myocardial ischaemia/necrosis as well as several echocardiography criteria were extracted from a prospectively collected database. Univariate and multivariate (logistic regression) analyses were performed with the "harvested heart" as dependent variable and the above-cited independent variables., Results: One hundred and eighty consecutive brain-dead patients admitted from 1st October 1998 to 31st December 2000 out of which 112 gave at least one organ were analyzed. Among these 112 patients, 59 (39 males and 20 females) were pre-selected as potential heart donors. Only 44 hearts were harvested. Logistic regression analysis showed that harvesting of the heart was more probable if the donor were a male, had no left ventricle systolic wall motion abnormalities, had low doses of norepinephrine and low serum troponin Ic concentrations., Conclusion: After an initial phase of selection, the final decision to harvest a heart is based on several criteria. These results should be an incentive to conceive a score that could allow a more formal decision process for heart harvesting.

A case of severe pulmonary oedema during beta2-adrenergic agonist tocolytic therapy (salbutamol) in a pregnant woman admitted for preterm labor at 32 weeks of amenorrhoea is reported. Echocardiography and haemodynamic investigations did not show any left ventricular systolic or diastolic dysfunction. Pulmonary oedema is an exceptional complication of beta2-adrenergic agonist tocolytic therapy. The diagnosis is considered in pregnant patients presenting with respiratory distress, associated with or following tocolytic therapy. Anaesthetic management of patients treated with a beta2-adrenergic agonist should take into consideration the delay between discontinuation of tocolytic therapy and anaesthetic induction, as well as volume expansion.