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We reviewed our experience with tracheal extubation in the operating room (E-OR) among cystic fibrosis patients requiring bilateral lung transplantation to evaluate safety and determine predictive factors of E-OR.The charts of 89 recipients (from May 2007 to June 2013) were analysed. Patients were divided into E-OR and E-ICU (intensive care unit extubation) groups. Data are expressed as numbers (percentages) or medians [25th-75th percentiles].There were 41 patients in the E-OR group (46%). Donor and recipient characteristics were similar between groups. Intraoperative complications occurred less frequently in the E-OR group, and fluid and transfusion requirements were lower. Postoperative courses were different in the E-OR group, including a lower rate of grade 3 primary graft dysfunction (0 compared with 19 patients, P0.0001) and shorter ICU (5.0 [3.7-7.2] compared with 11.5 [7.0-15.5] days) and hospital stays (22.0 [18.0-25.5] compared with 33.0 [25.0-56.5] days, respectively; P0.0001 for both). The 1 yr survival rates were similar: 95% in the E-OR group and 98% in the E-ICU group. A statistical model built on a development cohort of 60 randomly selected patients predicted 95% of E-OR instances in this cohort and 82% of E-OR instances in the validation cohort (28 patients). Predictive factors were complications during single-lung ventilation (second graft implantation), complications during bipulmonary ventilation (end of surgery), and the ratio of arterial partial pressure of oxygen to fractional inspired oxygen (end of surgery).Our protocol allowed for extubation of 46% of bilateral lung transplant patients without increased postoperative risks.

Background Intraoperative transesophageal echocardiographic visualization of the vascular anastomosis of lung grafts can be difficult. The goal of this prospective study was to compare intraoperative transesophageal echocardiography and contact ultrasound. Methods Vessel imaging and Doppler analysis obtained before chest closure by both techniques were compared in 18 bilateral lung transplant recipients. Results Twenty-four arteries in 36 and 45 pulmonary veins in 72 were recorded using transesophageal echocardiography versus 34 and 60 by contact ultrasound ( p = 0.05). Views of the left pulmonary artery ( p = 0.04) and of the left superior and inferior pulmonary veins ( p = 0.04 and p = 0.02, respectively) were more often obtained with contact ultrasound. Measurements of vessel diameters were similar by both methods except for the left superior vein, which was smaller by the transesophageal approach ( p = 0.002). In 1 patient, inferior venous diameters could not be obtained by either method. Nine arterial and 47 venous velocities were recorded by transesophageal echocardiography versus 21 and 33 by contact ultrasound ( p = 0.001). Contact ultrasound produced better left pulmonary artery recordings ( p = 0.02), whereas transesophageal echocardiography was more effective on venous velocities. Left inferior vein velocity was twofold higher using transesophageal echocardiography ( p Conclusions These results suggest clinicians should exercise caution when making treatment decisions when using transesophageal echocardiography alone.

UNLABELLED: The use of cuffed tracheal tubes in children younger than 8 yr of age has recently increased, although cuff hyperinflation may cause tracheal mucosal damage. In this study, we sought to measure the cuff pressure (P(cuff)) after initial free air inflation (iP(cuff)) and to follow its evolution throughout the duration of 50% nitrous oxide (N(2)O) anesthesia. One-hundred-seventy-four children, aged 0 to 9 yr, fulfilling the following criteria, were studied: 1). weight of 3-35 kg; 2). ASA physical status I or II; 3). elective surgery; 4). anesthesia with tracheal intubation using a cuffed tube and lasting at least 45 min; and 5). gas mixture containing 50% N(2)O. Free air inflation results in variable iP(cuff), with hyperinflation in 39% of cases. Numerous gas removals were required to maintain P(cuff) less than 25 cm H(2)O in 85% of the patients. The number of deflations decreased with the duration of mechanical ventilation and was small after 105 min. No difference was observed among the different cuffed tube sizes. We conclude that iP(cuff) is unpredictable after free air inflation and that numerous gas removals are required to maintain P(cuff) less than 25 cm H(2)O during N(2)O anesthesia in children. IMPLICATIONS: Free inflation of the tracheal tube cuff, controlled only by the palpation of the pilot balloon, is not reliable and results in extremely variable (and sometimes very high) initial cuff pressures in children. In addition, nitrous oxide anesthesia may result in cuff hyperinflation requiring numerous gas removals.

Introduction L’immuno-suppression consecutive a une transplantation d’organe associee au maintien d’une ventilation mecanique represente un risque infectieux majeur. Dans ce contexte precis, une extubation precoce au bloc operatoire des patients operes d’une transplantation pulmonaire bilaterale (TBP) constitue donc un challenge et est le fait de rares centres. Nous avons cette experience depuis quelques annees et cette etude vise a preciser les facteurs predictifs de succes d’une extubation au bloc operatoire (E-BO). Materiel et methodes Cette analyse repose sur une base de donnees dont l’exploitation a fin de recherche a recu l’accord du Comite d’ethique de la societe pneumologique de langue francaise. Cent trente-neuf patients ont beneficie d’une TBP pour mucoviscidose entre mai 2007 et Juin 2013. Les patients ont ete divises en 2 groupes : cohorte modele avec 2/3 des interventions randomisees pour limiter l’effet temps et une cohorte de validation. Une comparaison intra-groupe de patients extubes au BO (E-BO) et en reanimation (E-REA) a ete realisee. Une regression logistique a ensuite ete utilisee pour determiner les facteurs « patient » et « chirurgie » predisant la reussite de l’extubation au BO. Resultats Quarante et un patients etaient extubes precocement. Les caracteristiques des donneurs et receveurs sont similaires entre les groupes extubes et non. Les evenements respiratoires peroperatoires (p = 0,001) et l’insertion d’une ECMO (p = 0,02) ont ete moins frequents dans le groupe E-BO ; le remplissage par colloide (p = 0,01) et la transfusion (p = 0,01) ont ete moins importants dans le groupe E-BO. Un modele base sur les complications survenues durant la ventilation du premier greffon et celle des deux greffons, la transfusion de plaquettes, et le rapport PaO2/FiO2 a la fin de l’intervention predit 95 % des extubations au BO dans la cohorte de developpement et 82 % dans la cohorte de validation. L’evolution postoperatoire a ete plus favorable dans le groupe E-BO : dysfonction primaire du greffon grade 3 (0 vs 19 patients, p Discussion Notre protocole a permis l’extubation au BO de 46 % des patients sans accroissement du risque postoperatoire et avec une meilleure evolution postoperatoire precoce. La qualite du rapport P/F en fin d’intervention, l’absence de complications aux declampages et l’absence de transfusion plaquettaire sont les principaux facteurs de succes predictifs retrouves.

A fiberoptic examination is recommended at the end of lung transplantation for bronchial toilet and to check the bronchial anastomoses. This procedure permitted detection of a 10 × 4-mm piece of plastic of unknown origin in the left lingular bronchus and suggests that bronchoscopy should be performed before implanting the transplanted lung.

Following the death in France by acute aortic dissection of two women with Turner syndrome who were pregnant following oocyte donation, the Director of the French Biomedicine Agency (Agence de la biomedecine) sent a letter to the President of the French College of Obstetricians and Gynaecologists (FCOG). He requested the College's expertise in reviewing point-by-point the cases and risk factors and in determining whether there are grounds to propose additional measures complementary to the recommendations made by the Haute autorite de sante or French National Authority for Health (HAS) in 2008 in terms of indication and monitoring of patients. A joint practice committee of the FCOG, the French Cardiologic Society, the French Chest and Cardiovascular Surgery Society, the French Society of Anaesthesia and Intensive Care, the French Endocrine Society, the French study group for oocyte donation, and the Biomedicine Agency defined the exact questions to be put to the experts, chose these experts, followed them up and drafted the synthesis of recommendations resulting from their work. The questions concerned the check-up before pregnancy of Turner patients, contraindication and acceptance of pregnancy, information for the patients, and recommendations for antenatal care, delivery and postnatal follow-up.

Background The incidence and significance of troponin I release and its mechanism are unknown in severe trauma patients. The characteristics of this release were prospectively studied in such patients and correlated with presence of shock, existence of myocardial contusion, and outcome. Methods During a 24-month period, serial electrocardiogram recordings and troponin I measurements were performed in all trauma patients admitted at a surgical intensive care unit. The diagnosis of a significant myocardial contusion was made on electrocardiographic criteria. According to the time course of troponin I, three groups of patients were defined a priori: very transient (/= 2 microg/l), and sustained (> 36 h) and significant release (troponin I > 2 microg/l). In the last group, coronary artery angiography was performed. Results The incidence of troponin I release was 12% (95% confidence interval [CI], 9.6-14.4%) in 728 patients. A significant myocardial contusion was found in 35 patients (5%; 95% CI, 3.4-6.6%) and may occur in the absence of chest trauma and without troponin I release. Sensitivity, specificity, and positive and negative predictive values of troponin I for the diagnosis of myocardial contusion were 63, 98, 40, and 98%, respectively. Troponin I release was observed in 54 early (> 48 h) survivors (7%; 95% CI, 5.6-9.6%) without preexisting coronary artery disease. A sustained and significant release of troponin I (17 patients) was frequently associated with chest trauma (82%) and constantly with electrocardiographic abnormalities. A coronary artery injury was found in 7 patients (2 major and 5 minor vascular injuries) (1% of the whole group; 95% CI, 0.4-2.0%). Mortality was similar in early survivors with (15%; 95% CI, 7-27%) or without (12%; 95% CI, 9-14%) troponin I release. The odds ratio for late mortality was 1.32 (95% CI, 0.61-2.85) in patients with troponin I release. Conclusions Serial electrocardiogram recordings and troponin I assessments may be proposed for initial screening in high-risk trauma patients to detect anatomical cardiac injuries through the time course of circulating protein. Troponin I release does not have a prognosis value in trauma patients.

We studied the consequences of an early phase of TNFalpha-induced LV dysfunction and of its treatment by isoproterenol on an isolated rabbit heart preparation. Two dosages of TNFalpha (2 and 4 microg) were infused, followed by isoproterenol (ISO), infused by increasing concentrations from 10 to 10 M. Left ventricular developed pressure (DP) was recorded. Creatine kinase (CKtot) and cardiac Troponin I (cTnI) were measured in the effluent perfusate. An anatomic score was calculated by histologic examination of the hearts while a structural analysis of cTnI was done. TNFalpha induced a dose-dependent decrease in DP (-43 +/- 18% for 4 microg) without change in coronary vascular resistances, which was not followed by biochemical or structural abnormalities. TNFalpha reduced the maximum effect (Emax) of ISO on DP (mean DeltaDPmaxISO = -40% for 4 microg) without change in the concentration leading to half Emax (ED50ISO). ISO treatment of TNFalpha (4 microg)-induced LV dysfunction resulted in a selective release of cTnI, myocardial tissue contraction bands, and a significant proteolysis of cTnI. Within the limits of the model, the myocardial injury reported during severe sepsis would not be related to an early cytotoxic effect of TNFalpha but could be attributed to an enhancement of the effects of isoproterenol by TNFalpha.