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Background: Preoperative identification of patients with hemostasis abnormalities leading to an increased bleeding risk is based on routine hemostasis tests: prothrombin time (PT), activated partial thromboplastin time (APTT), and platelet count. Because of their low predictive performance, guidelines recommend replacing them with structured bleeding risk questionnaires, but none is validated in this population., Objectives: To assess the diagnostic accuracy of 3 strategies, performed at the preanesthesia visit before scheduled interventions, and to identify patients with hemostasis abnormalities leading to an increased bleeding risk METHODS: A multicenter study was performed in 7 French academic hospitals, involving patients scheduled for surgical intervention, without antiplatelet/anticoagulant treatment. The 3 strategies consisted of 1-a structured screening questionnaire; 2-PT, APTT, and platelet count ordered in selected patients; and 3-systematic PT, APTT, and platelet count. The reference standard comprised von Willebrand factor activity/antigen, factor (F)VIII, FIX, FXI, platelet function analyzer, and, when required, FII, FV, FX, and FVII and hemostasis consultation., Results: Eighteen (1.2%) of 1484 patients had a hemostasis abnormality leading to an increased bleeding risk according to reference standard. In the overall cohort, sensitivity of the questionnaire-based strategy was 50% (95% CI, 26%-74%; specificity, 87% [95% CI, 85%-88%]); sensitivity was 0% (95% CI, 0%-41%) in men vs 82% (95% CI, 48%-98%) in women. For selective routine tests, sensitivity was 33% (95% CI, 13%-59%) and specificity 97% (95% CI, 96%-98%). Corresponding values for systematic routine tests were 44% (95% CI, 22%-69%) and 93% (95% CI, 91%-94%)., Conclusion: Sensitivity was low for all 3 strategies investigated. The structured screening questionnaire had clinically acceptable diagnostic accuracy only in women., Competing Interests: Declaration of competing interests There are no competing interests to disclose., (Copyright © 2024 International Society on Thrombosis and Haemostasis. Published by Elsevier Inc. All rights reserved.)

Background: Neuromuscular blocking agents (NMBAs) are among the leading cause of perioperative anaphylaxis, and most of these reactions are IgE mediated. Allergic sensitisation induced by environmental exposure to other quaternary ammonium-containing compounds, such as pholcodine, has been suggested. The aim of this study was to assess the relationship between pholcodine exposure and NMBA-related anaphylaxis., Methods: ALPHO was a multicentre case-control study, comparing pholcodine exposure within a year before anaesthesia between patients with NMBA-related perioperative anaphylaxis (cases) and control patients with uneventful anaesthesia in France. Each case was matched to two controls by age, sex, type of NMBA, geographic area, and season. Pholcodine exposure was assessed by a self-administered questionnaire and pharmaceutical history retrieved from pharmacy records. The diagnostic values of anti-pholcodine and anti-quaternary ammonium specific IgE (sIgE) were also evaluated., Results: Overall, 167 cases were matched with 334 controls. NMBA-related anaphylaxis was significantly associated with pholcodine consumption (odds ratio 4.2; 95% confidence interval 2.3-7.0) and occupational exposure to quaternary ammonium compounds (odds ratio 6.1; 95% confidence interval 2.7-13.6), suggesting that apart from pholcodine, other environmental factors can also lead to sensitisation to NMBAs. Pholcodine and quaternary ammonium sIgEs had a high negative predictive value (99.9%) but a very low positive predictive value (<3%) for identifying NMBA-related reactions., Conclusions: Patients exposed to pholcodine 12 months before NMBA exposure have a significantly higher risk of an NMBA-related anaphylaxis. The low positive predictive values of pholcodine and quaternary ammonium sIgEs precludes their use to identify a population with a high risk of NMBA-related anaphylaxis., Clinical Trial Registration: NCT02250729., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: In the Île-de-France region (henceforth termed Greater Paris), extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) was considered early in the COVID-19 pandemic. We report ECMO network organisation and outcomes during the first wave of the pandemic., Methods: In this multicentre cohort study, we present an analysis of all adult patients with laboratory-confirmed SARS-CoV-2 infection and severe ARDS requiring ECMO who were admitted to 17 Greater Paris intensive care units between March 8 and June 3, 2020. Central regulation for ECMO indications and pooling of resources were organised for the Greater Paris intensive care units, with six mobile ECMO teams available for the region. Details of complications (including ECMO-related complications, renal replacement therapy, and pulmonary embolism), clinical outcomes, survival status at 90 days after ECMO initiation, and causes of death are reported. Multivariable analysis was used to identify pre-ECMO variables independently associated with 90-day survival after ECMO., Findings: The 302 patients included who underwent ECMO had a median age of 52 years (IQR 45-58) and Simplified Acute Physiology Score-II of 40 (31-56), and 235 (78%) of whom were men. 165 (55%) were transferred after cannulation by a mobile ECMO team. Before ECMO, 285 (94%) patients were prone positioned, median driving pressure was 18 cm H 2 O (14-21), and median ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen was 61 mm Hg (IQR 54-70). During ECMO, 115 (43%) of 270 patients had a major bleeding event, 27 of whom had intracranial haemorrhage; 130 (43%) of 301 patients received renal replacement therapy; and 53 (18%) of 294 had a pulmonary embolism. 138 (46%) patients were alive 90 days after ECMO. The most common causes of death were multiorgan failure (53 [18%] patients) and septic shock (47 [16%] patients). Shorter time between intubation and ECMO (odds ratio 0·91 [95% CI 0·84-0·99] per day decrease), younger age (2·89 [1·41-5·93] for ≤48 years and 2·01 [1·01-3·99] for 49-56 years vs ≥57 years), lower pre-ECMO renal component of the Sequential Organ Failure Assessment score (0·67, 0·55-0·83 per point increase), and treatment in centres managing at least 30 venovenous ECMO cases annually (2·98 [1·46-6·04]) were independently associated with improved 90-day survival. There was no significant difference in survival between patients who had mobile and on-site ECMO initiation., Interpretation: Beyond associations with similar factors to those reported on ECMO for non-COVID-19 ARDS, 90-day survival among ECMO-assisted patients with COVID-19 was strongly associated with a centre's experience in venovenous ECMO during the previous year. Early ECMO management in centres with a high venovenous ECMO case volume should be advocated, by applying centralisation and regulation of ECMO indications, which should also help to prevent a shortage of resources., Funding: None., Competing Interests: Declaration of interests GL reports lecture fees from Livanova and Abiomed, outside of the submitted work. MS reports lecture fees from Getinge, Dräger, and Xenios, outside of the submitted work. BC reports consulting and lecture fees from Edwards Lifesciences, Orion Pharma, Amomed, and Nordic Pharma, outside of the submitted work. RS has received lecture fees from Baxter, outside of the submitted work. DL reports speaker fees and is a member of advisory boards for Edwards Lifesciences, Medtronic, and Masimo, outside of the submitted work. AC reports grants and personal fees from Getinge, and personal fees from Baxter and Xenios, outside of the submitted work. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Prompt diagnosis of intra-anaesthetic acute hypersensitivity reactions (AHR) is challenging because of the possible absence and/or difficulty in detecting the usual clinical signs and because of the higher prevalence of alternative diagnoses. Delayed epinephrine administration during AHR, because of incorrect/delayed diagnosis, can be associated with poor prognosis. Low end-tidal CO2 (etCO2) is known to be linked to low cardiac output. Yet, its clinical utility during suspected intra-anaesthetic AHR is not well documented., Methods: Clinical data from the 86 patients of the Neutrophil Activation in Systemic Anaphylaxis (NASA) multicentre study were analysed. Consenting patients with clinical signs consistent with intra-anaesthetic AHR to a neuromuscular blocking agent were included. Severe AHR was defined as a Grade 3-4 of the Ring and Messmer classification. Causes of AHR were explored following recommended guidelines., Results: Among the 86 patients, 50% had severe AHR and 69% had a confirmed/suspected IgE-mediated event. Occurrence and minimum values of arterial hypotension, hypocapnia and hypoxaemia increased significantly with the severity of AHR. Low etCO2 was the only factor able to distinguish mild [median 3.5 (3.2;3.9) kPa] from severe AHR [median 2.4 (1.6;3.0) kPa], without overlap in inter-quartile range values, with an area under the receiver operator characteristic curve of 0.92 [95% confidence interval: 0.79-1.00]. Among the 41% of patients who received epinephrine, only half received it as first-line therapy despite international guidelines., Conclusions: An etCO2 value below 2.6 kPa (20 mm Hg) could be useful for prompt diagnosis of severe intra-anaesthetic AHR, and could facilitate early treatment with titrated doses of epinephrine., Clinical Trial Registration: NCT01637220., (© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com)

Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps., (Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

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.)

A 32 year old parturient with a history of Tako-tsubo cardiomyopathy, who suffered from postpartum hemorrhage for which sulprostone was administered without any adverse events, is reported. Anesthetic considerations related to the management of patient with a history of Tako-tsubo cardiomyopathy, especially triggers that may cause a recurrence, are described. The potential deleterious effects of sulprostone in a patient with a history of Tako-tsubo cardiomyopathy are discussed., (Copyright © 2013 Elsevier Inc. 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.)

Background: Chronic stress during pregnancy has been associated with worsened maternal and fetal outcomes. Acute stress immediately before spinal anaesthesia for caesarean section may contribute to hypotension. Therefore objective measures of acute stress may help identify women at risk of adverse outcomes. Salivary alpha-amylase is a stress biomarker that has so far been poorly investigated during pregnancy. The reference change value is the difference between two sequential results that must be exceeded for a change to be considered clinically relevant. Our first aim was to determine if salivary alpha-amylase increased in pregnant patients when subjected to the stress of transfer to the operating room. Our second aim was to determine if changes in salivary alpha-amylase were likely to be clinically significant by measuring reference change value in healthy volunteers., Methods: In 15 pregnant patients undergoing planned caesarean section under spinal anaesthesia, salivary alpha-amylase, systolic blood pressure, heart rate, and immediate anxiety were measured on the morning of surgery on the ward and again in the operating room. The reference change value was calculated from 18 healthy volunteers., Results: A median 220% increase in salivary alpha-amylase activity (P=0.0015) and a 17% increase in systolic blood pressure (P=0.0006) were observed between the ward and operating room. No changes of immediate anxiety or heart rate were observed. Reference change value was ±76% in volunteers and 13 of the 15 pregnant patients had a salivary alpha-amylase increase greater than the reference change value., Conclusion: When pregnant women are taken to the operating room, a clinically and statistically significant increase in salivary alpha-amylase was observed. Further studies are required to define its clinical usefulness., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Background: Patients receiving anti-platelet agents for secondary cardiovascular prevention frequently require non-cardiac surgery. A substantial proportion of these patients have their anti-platelet drug discontinued before operation; however, there is uncertainty about the impact of this practice. The aim of this study was to compare the effect of maintenance or interruption of aspirin before surgery, in terms of major thrombotic and bleeding events., Methods: Patients treated with anti-platelet agents for secondary prevention and undergoing intermediate- or high-risk non-cardiac surgery were included in this multicentre, randomized, placebo-controlled, trial. We substituted non-aspirin anti-platelets with aspirin (75 mg daily) or placebo starting 10 days before surgery. The primary outcome was a composite score evaluating both major thrombotic and bleeding adverse events occurring within the first 30 postoperative days weighted by their severity (weights were established a priori using a Delphi consensus process). Analyses followed the intention-to-treat principle., Results: We randomized 291 patients (n=145, aspirin group, and n=146, placebo group). The most frequent surgical procedures were orthopaedic surgery (52.2%), abdominal surgery (20.6%), and urologic surgery (15.5%). No significant difference was observed neither in the primary outcome score [mean values (SD)=0.67 (2.05) in the aspirin group vs 0.65 (2.04) in the placebo group, P=0.94] nor at day 30 in the number of major complications between groups., Conclusions: In these at-risk patients undergoing elective non-cardiac surgery, we did not find any difference in terms of occurrence of major thrombotic or bleeding events between preoperative maintenance or interruption of aspirin.

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.)

Purpose: The management of bronchial fistula associated with acute lung injury raises two major concerns: (1) high ventilation pressures are necessary for lung recruitment but detrimental for fistula healing, and (2) adequate lung recruitment is prevented by large air leak. Primary surgical closure of bronchial fistula should be attempted but is rarely successful during mechanical ventilation. We sought to evaluate the efficacy of extracorporeal membrane oxygenation associated with lung-protective ventilation in case of failure of conventional management., Description: Arteriovenous extracorporeal membrane oxygenation was initiated by femorofemoral cannulation. A stepwise increase of extracorporeal membrane oxygenation output and a decrease of mechanical ventilation settings were simultaneously performed, aiming at lung-protective ventilation., Evaluation: During a 1-year period, this protocol management was used in 5 patients with refractory respiratory failure associated with bronchial fistula after thoracic operations. This strategy allowed fistula healing in 3 patients., Conclusions: If correctly timed, extracorporeal membrane oxygenation can provide a therapeutic bridge to lung-protective ventilation and allow bronchial fistula healing in case of refractory respiratory failure., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. 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.

Background: Increased plasma cardiac troponin I (cTnI) values in heart donors are associated with donor myocardial dysfunction and increased risk of rejection in the recipients. We investigated the association between cTnI values and myocardial dysfunction in potential heart donors and the relationship between donors' cTnI values and recipients' early myocardial function and 1 year survival and risk of rejection., Methods: cTnI was measured in 159 consecutive potential heart donors. Myocardial function was estimated by the left ventricular ejection fraction (LVEF) and segmental wall motion abnormalities (SWMA). Results are mean+/-SD (range) or median (interquartile range)., Results: cTnI values in potential donors were 2.1+/-5 ng/ml (0-40.4 ng/ml); cTnI values were significantly (P<0.001) higher: 4.2+/-5.9 ng/ml (0-30.6 ng/ml) for potential donors with LVEF <50% versus LVEF >50%: 1.7+/-4.7 ng/ml (0-40.4 ng/ml). cTnI values were significantly lower for donors without SWMA. cTnI values were significantly (P<0.001) lower for the 90 donors whose hearts were harvested: 1.1+/-2.3 ng/ml (0-15.6 ng/ml) versus the not harvested: 3.6+/-6.9 ng/ml (0-40.4 ng/ml). There were 87 recipients followed for 1 year. Donors' cTnI values were not associated with early alteration of LVEF, incidence of rejection or 1 year recipients' survival., Conclusion: Increased cTnI values in potential heart donors are statistically associated with myocardial dysfunction and could be helpful for organ selection. In contrast, cTnI values in heart donors were not associated with graft dysfunction or recipient survival after transplantation.

C-reactive protein (CRP) is an independent predictor of atherosclerosis and its complications. Monocytes/macrophages are implicated in this complex disease which is, among other mechanisms, characterised by angiogenesis. The aim of this study was to analyse whether CRP plays a role in VEGF-A regulation by monocytic cells. Our findings show that CRP up-regulates VEGF-A mRNA expression and protein excretion in THP-1 cells in a concentration- and time-dependent manner. Furthermore, we studied the signaling pathway underlying this effect. CRP increases VEGF-A expression via a PI3-kinase and an extracellular-signal-regulated kinase (ERK) 1/2 dependent pathway. Our results suggest that CRP could play a role in the angiogenesis process via immune cells such as monocytes.

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.

A 40 year-old 2nd gesta pregnant woman (34.5 weeks of amenorhea) was admitted to hospital for abdominal pain and arterial hypotension which were rapidly related to a retroperitoneal haematoma due to left kidney bleeding. Emergency cesarean delivery under general anaesthesia was undertaken because of foetal distress. Exploration of the retroperitonal space after foetal extraction confirmed the presence of a large haematoma and abnormal left renal morphology. The retroperitoneal space was drained without any further intervention. Subsequently, abdominal and thoracic computerised tomographic examination showed bilateral dysplasia of the kidneys and pulmonary cysts consistent with the diagnosis of renal angiomyolipoma and pulmonary lymphangioleiomyomatosis. The case report is of interest because of the circumstances of discovery of the disease and because nephrectomy was not necessary to control the bleeding of the left kidney. Six months after the incident the patient and the child are in good condition.

The aim is to perform a literature search on the role of pregnancy in the rupture of renal angiomyolipoma. Articles published from 1952 to 2004 in the Medline database were searched using the keywords renal angiomylipoma and pregnancy. Pathologies associated with angiomylipoma (lymphangioleiomyomatosis and Bourneville tuberous sclerosis) were taken into account. Seventy-two cases of association of renal angiomyolipoma and pregnancy were found, out of which 58 presented a haemorrhage. In only 26% of the cases, renal angiomyolipoma had been documented prior to pregnancy. Clinical presentation was similar to cases occurring among non pregnant women: abdominal pains (88%), hypotension or shock (33%) and hematuria (24%). Average size of the rupture was 11,7 cm. Rupture does not occur solely with the first pregnancy but occurred equally during the first, second and third pregnancy. Average gestation age upon occurrence of haemorrhage was 27 weeks with a minimum at ten weeks. Therapeutic strategies at the time of shock or hypotension were total nephrectomy in 79% of the cases, 7% polar nephrectomy, 7% embolisation followed by nephrectomy and 7% abstention. A causal role of pregnancy in the atraumatic rupture of angiomyolipoma is not clearly defined. Nevertheless, many arguments (whether it be abdominal mechanical pressure, hormonal or histological ones) suggest that a pregnancy could increase the risk of renal angiomyolipoma rupture. These patients should have a medical follow-up period at closer intervals during their pregnancy and the postpartum phase.

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.

The cardiovascular effects of hemoglobin-based oxygen carriers (HBOCs) are mainly related to their nitric oxide (NO) scavenging properties but other effects such as the impact of these hemoglobins on the endothelial cell (EC) biology are not well understood. We hypothesized that HBOCs could modify EC functions by altering gene expression, in particular the endothelial NO synthase (NOS3) and/or by activating EC. Cultured human aortic endothelial cells (HAEC) were incubated for 3 hours with purified cell-free Hb, Dex-BTC-Hb or alpha alpha-Hb (16 g/L). Expression of NOS3 mRNA and protein were assessed by semi-quantitative RT-PCR and Western blot respectively immediately after and 24 hours after incubation. The expression and localization of the adhesion molecule ICAM-1 were detected by fluorescence microscopy. None of the solutions tested modified NOS3 mRNA and protein expression despite adequate controls that up- or down-regulate NOS3 expression. The expression and the localization of ICAM-1 on the cell membrane were modified after 3 hours of incubation with all the hemoglobin solutions tested in a manner similar to tumor necrosis factor-alpha. In conclusion, HAEC incubation with clinically relevant concentrations of HBOCs induced changes in the pattern of ICAM-1 expression consistent with cell activation/cell signaling mechanisms. However, HBOCs did not alter NOS3 gene expression.

Vitamin A and its active metabolite retinoic acid (RA) modulate host-pathogen interactions by interfering with the host immune and inflammatory response including prostaglandin (PG) biosynthesis. The effects of RA on phospholipase A(2) (PLA(2)) and cyclooxygenase (COX) isoforms in vitro are controversial, and few in vivo studies exist. We investigated the in vivo effects of RA on PG biosynthesis in the presence or absence of lipopolysaccharide (LPS) in rats. RA alone [10 mg/(kg. d) for 5 d] increased plasma and liver PG concentrations by increasing COX-1 protein expression (twofold that of control rats). RA acted synergistically with LPS to increase plasma (400-fold) and liver (15-fold) concentrations of prostaglandin E(2) (PGE(2)) and significantly, but to a lesser extent, other PG compared with RA rats, in the absence of major differences in PLA(2) expression or activity or COX-1 and COX-2 mRNA or protein expression. The RA + LPS-mediated increase in PGE(2) was significantly attenuated (97%) by aminoguanidine (AG), a relatively specific inhibitor of the inducible nitric oxide synthase (NOS2), consistent with the previously reported synergistic effect of RA and LPS on NOS2 expression and activity. In addition, RA and LPS induced the expression of the microsomal isoform of PGE synthase (mPGES). In conclusion, in vivo, RA and LPS increased PG and especially PGE(2) concentrations. The PGE(2) increase was associated with NOS2-mediated activation of COX and induction of mPGES. These results contribute to the characterization of the effects of vitamin A on the host inflammatory response.

Complex interactions between the L-arginine/nitric oxide synthase (NOS) pathway and the sympathetic nervous system have been reported. Methods capable of measuring L-arginine and norepinephrine (NE) have mainly been reported for plasma. We report the use of the microdialysis technique combined with high-performance liquid chromatography (HPLC) for measurement of both L-arginine and NE within the same tissue microdialysis sample. The microdialysis probe consisted of linear flexible probes (membrane length: 10 mm, outside diameter: 290 microm, molecular weight cut-off 50 kDa). The method used for L-arginine measurement was HPLC with fluorescence detection, giving a within-run and a between-day coefficient of variation of 2.9 and 12.8%, respectively. The detection limit was 0.5 pM/20 microl injected for L-/D-arginine. The method used for NE measurement was HPLC with electrochemical detection. The coefficients of variation were 4% for within-assay precision and 7.5% for between-assay precision. The detection limit for NE was 1 fmol/20 microl injected. The microdialysis technique coupled with HPLC system was validated in vivo to measure muscular interstitial concentrations of both arginine and NE under baseline conditions and after intravenous infusion of 500 mg/kg of L-arginine or D-arginine. In conclusion, the microdialysis technique coupled to HPLC allows the simultaneous measurements of both L-arginine and NE within the same tissue microenvironment and will enable the study of the complex interactions between the L-arginine/NO pathway and sympathetic nervous system within the interstitial space of different organs.

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.