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The most recent recommendations support learning of external cardiac massage (ECM) through feedback devices.The objective was to compare the effects on immediate and 3-month retention of ECM technical skills when using feedback devices compared with training without feedback as part of a half-day training session in medical students.This randomized study was performed using the Resusci Anne QCPR manikin in 64 medical students. We compared the quality of ECM with nonfeedback training in the control group (group 1) vs. 2 feedback learning methods (group 2, PocketCPR and group 3, Skill Reporter each used with visual display available to the trainee). At the end of the training session and 3 months later, students performed chest compressions blindly during a 2-min assessment session. The median compression score was the primary outcome for assessing immediate and long-term retention.Regarding immediate retention, the median compression score was significantly lower in group 1 (23%) than in groups 2 (81%) and 3 (72%) (p 0.05) with no difference between the 2 feedback methods. At 3 months, mean compression scores remained high but not significantly different between the 2 feedback groups.The use of a feedback device used for ECM training improves the quality of immediate retention of technical ECM skills compared with traditional teaching in medical students. At 3 months, the 2 groups with feedback retained a high level of performance. No significant difference could be demonstrated between the 2 feedback methods.

Background Individualized hemodynamic management during surgery relies on accurate titration of vasopressors and fluids. In this context, computer systems have been developed to assist anesthesia providers in delivering these interventions. This study tested the hypothesis that computer-assisted individualized hemodynamic management could reduce intraoperative hypotension in patients undergoing intermediate- to high-risk surgery. Methods This single-center, parallel, two-arm, prospective randomized controlled single blinded superiority study included 38 patients undergoing abdominal or orthopedic surgery. All included patients had a radial arterial catheter inserted after anesthesia induction and connected to an uncalibrated pulse contour monitoring device. In the manually adjusted goal-directed therapy group (N = 19), the individualized hemodynamic management consisted of manual titration of norepinephrine infusion to maintain mean arterial pressure within 10% of the patient’s baseline value, and mini-fluid challenges to maximize the stroke volume index. In the computer-assisted group (N = 19), the same approach was applied using a closed-loop system for norepinephrine adjustments and a decision-support system for the infusion of mini-fluid challenges (100 ml). The primary outcome was intraoperative hypotension defined as the percentage of intraoperative case time patients spent with a mean arterial pressure of less than 90% of the patient’s baseline value, measured during the preoperative screening. Secondary outcome was the incidence of minor postoperative complications. Results All patients were included in the analysis. Intraoperative hypotension was 1.2% [0.4 to 2.0%] (median [25th to 75th] percentiles) in the computer-assisted group compared to 21.5% [14.5 to 31.8%] in the manually adjusted goal-directed therapy group (difference, −21.1 [95% CI, −15.9 to −27.6%]; P < 0.001). The incidence of minor postoperative complications was not different between groups (42 vs. 58%; P = 0.330). Mean stroke volume index and cardiac index were both significantly higher in the computer-assisted group than in the manually adjusted goal-directed therapy group (P < 0.001). Conclusions In patients having intermediate- to high-risk surgery, computer-assisted individualized hemodynamic management significantly reduces intraoperative hypotension compared to a manually controlled goal-directed approach. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

INTRODUCTION The growing number of learners implies that all of them cannot play an active role during high-fidelity scenarios. Studies suggest a positive educational value when learners are observers only, but it remains uncertain whether learning outcomes might be improved by using an observer tool (OT). METHODS Eighty-nine anesthesia residents were randomized to use an OT (n = 44, OT+; based on a cognitive aid) or not (n = 45, OT-) when not role-playing. The main outcome parameter was the learning outcomes assessed by comparing the change (before-after) in the response score to a questionnaire dedicated to medical knowledge obtained in the OT+ and OT- groups. The impact of using the OT was also assessed by measuring the perceived stress level and the change of the Anesthetists' Non-Technical Skill items values. RESULTS At the end of the session, the mean medical knowledge score (mean ± SD) was higher in the OT+ group than in the OT- group (11.4 ± 2.7 vs. 9.6 ± 2.4, respectively, P = 0.0008). The mean Anesthetists' Non-Technical Skill score and level of stress perceived did not differ between groups. Trainees rated similarly the learning value and satisfaction related to the simulation course. CONCLUSIONS This study suggests that observing high-fidelity simulation scenarios using an OT based on a cognitive aid increases the medical knowledge gain when compared with that seen in passive observers. This study suggests that the use of an OT improves the educational value of simulation.

Purpose Nausea and vomiting is the main cause of failure of enhanced recovery protocol (ERP) after right hemicolectomy. Methods From January 2013 to January 2018, all patients undergoing right hemicolectomy were prospectively included. Patients undergoing emergency surgery, additional complex procedure or temporary stoma, nasogastric tube (NGT) maintenance, or abdominal drainage were excluded. Failure of ERP was defined as nausea/vomiting precluding oral feeding after POD3 and/or the occurrence of postoperative ileus requiring NGT and/or length of stay (LOS) ≥ 8 days except for patients awaiting admission in rehabilitation unit. Risk factors of failure of ERP were identified using univariate and multivariate analysis. Results Among 306 patients undergoing right hemicolectomy, 140 fulfilled the inclusion criteria. Postoperative morbidity was 31%, and the mortality rate was nil. The mean postoperative hospital stay was 7 days (range 2–30). Successful ERP was achieved in 83 patients (59%). Causes of failure were major nausea/vomiting precluding oral feeding after POD3 in 36, postoperative ileus requiring NGT in 16 and LOS ≥ 8 days in 36. On multivariate analysis, preoperative anemia (OR 5.2; CI 95%, 1.3–21.1, p = 0.02) and platelet anti-aggregant/anti-coagulant (OR 4.5; CI 95%, 1.7–12.1, p = 0.003) were associated with the risk of failure of ERP. Conclusion This study shows that anemia and medication with antiplatelet/anticoagulation therapy increase the risk of failure of ERP after right hemicolectomy that translates most of the time by nausea/vomiting and postoperative ileus. The presence of these factors should lead to adapt the strategy to improve outcome rather than be considered as contraindication to ERP.

Because of difficulties in placing catheters and inconsistent analgesic spread,[1][1] thoracic paravertebral catheter (TPVC) is not routinely used. Factors that influence perineural catheter success placement and efficacy are: technical approach,[2][2] length of catheter threaded into the space

Resume L’utilisation du masque larynge est devenue courante en anesthesie pour le controle des voies aeriennes. La mise sur le marche reguliere de nouveaux dispositifs devrait etre suivie de leur evaluation clinique afin d’ameliorer les pratiques au benefice des patients. L’accompagnement lors de l’utilisation d’un nouveau dispositif passe par l’integration des regles de bonne pratique, une lecture des recommandations du fabricant et une formation pratique. Le choix raisonne du dispositif en fonction du patient, du type d’anesthesie, de la procedure envisagee et de l’expertise du praticien devrait permettre d’optimiser les echanges gazeux et de diminuer le risque de complications parfois graves comme l’inhalation du contenu gastrique.

Resume La survenue d’accidents rares mais graves que sont l’hyperthermie maligne et l’intoxication aux anesthesiques locaux impose de detenir pret a l’usage des agents therapeutiques. Leur utilisation exceptionnelle necessite la redaction de procedures dans l’eventualite de leur usage qui se produit toujours dans des circonstances dramatiques.

Resume La colectomie est une intervention frequente dont la realisation est de plus en plus effectuee par laparoscopie. La plupart des strategies de prise en charge de la douleur postoperatoire ont ete decrites apres laparotomie. La douleur apres laparoscopie etant moins intense, elle modifie la prise en charge de la douleur postoperatoire. Une technique telle que l’analgesie peridurale qui constitue la reference apres laparotomie ne se justifie plus apres laparoscopie. Il importe cependant de limiter la quantite d’opiaces administres de facon a reduire leur consequences sur la reprise du transit. Cette strategie repose sur une approche multimodale associant l’utilisation d’antalgiques non opiaces et l’administration d’agents anti hyperalgesiques tels que la lidocaine intraveineuse et la ketamine. La reprise rapide de l’alimentation orale et de la deambulation reste une partie integrante de la strategie de rehabilitation postoperatoire apres chirurgie laparoscopique comme apres une laparotomie.

Pneumonectomy carries a high-risk for postoperative complications. The aim of the study was to identify factors that may predispose to the development of major postoperative complications after pneumonectomy for lung cancer. All consecutive patients from January 2000 to December 2005 were retrospectively studied. Major postoperative complications were defined by respiratory failure, pulmonary embolism, pneumonia, shock, cardiogenic pulmonary oedema, myocardial ischaemia or symptomatic cardiac arrhythmia. One hundred and twenty-nine patients were included. The overall hospital mortality rate was 10.8%, and complications occurred in 42.6%. Multivariate analysis revealed that patients with American Society of Anesthesiologist (ASA) class >2 [odds ratio (OR) 8.26; 95% confidence interval (CI), 3.19-36.55] and liberal fluid administration during surgery (OR, 1.96 for each litre; 95% CI, 1.45-3.16) to be risk factor for major cardiopulmonary complication or mortality. Preoperative haemoglobin > or =10 g/dl (OR, 0.19; 95% CI, 0.01-0.91) and low tidal volume administrated during surgery (< or =7.35 ml/kg; OR, 0.36; 95% CI, 0.10-0.92) were identified as protective factors. Pneumonectomy remains a high-risk surgery. Postoperative complications may be influenced by the comorbidities but also the management of fluid infusion and mechanical ventilation during the surgical procedure.

Introduction L’hypothermie ( Materiel et methodes L’objectif de ce travail etait d’evaluer le rapport cout–efficacite de la prevention de l’hypothermie peroperatoire dans la prevention de l’ISO. Quatre methodes de prevention d’hypothermie peroperatoire etaient prises en compte : couverture chauffante a air pulse (CC), rechauffeur de solutes a bas debit (RF), association des deux et absence de rechauffement actif. Le modele clinique retenu a ete la tumorectomie du sein chez des patientes ayant un faible risque d’ISO (NNIS-0). Un modele de decision analytique a ete elabore comparant les 4 strategies de prevention ; a l’issue de chaque intervention trois etats de transition etaient possibles : ISO superficielle, profonde ou absence d’ISO. Les donnees d’efficacite clinique des differentes strategies ont ete definies a partir des donnees de la litterature et du NICE. Les donnees sur la frequence de l’ISO dans la chirurgie du sein etaient issues du rapport national RAISIN 2011–2012. L’horizon temporel considere etait la periode allant jusqu’a 30 jours postoperatoires. Le point de vue adopte etait celui de l’assurance maladie. Les couts hospitaliers etaient estimes par les tarifs des GHM. Les couts des soins de ville ont ete evalues a partir des tarifs de la Securite sociale. Seuls, les couts directs ont ete pris en compte. Une analyse de sensibilite a ete planifiee pour les patients presentant un score NNIS-1 (score ASA ≥ 3 ou duree de la chirurgie superieure a 95 min). Resultats Un arbre decisionnel a ete concu pour illustrer les differentes probabilites pour chacune des 4 strategies. Le Tableau 1 indique les couts des strategies de prevention et de l’ISO. Pour chaque strategie un effectif de 1000 patients a ete considere. La Fig. 1 illustre le rapport cout–efficacite de chaque strategie de prevention chez les patientes a bas risque d’ISO. Pour les patients ayant un score NNIS-1 la strategie associant CC avec RF etait la plus cout–efficace. Discussion Le rechauffement actif est une strategie cout–efficace par rapport au controle. Le rechauffement par CC est la strategie dominante dans la chirurgie mineure a risque d’ISO (NNIS-0). Dans le cas d’un risque d’ISO intermediaire (NNIS-1), la strategie associant le rechauffement par CC avec le RF a montre etre la strategie dominante.

BACKGROUND: That thrombocytopenia results in increased mortality or transfusion requirements has not been confirmed by previous studies. We performed a case-control study in which 36 patients who developed severe thrombocytopenia of less than 50x109 platelets/l were carefully matched for the severity of underlying disease and other important variables. RESULTS: Seventeen (47%) thrombocytopenic patients died, versus 10 (28%) matched control patients who were not thrombocytopenic.Nine pairs had a discordant outcome, and in eight of these pairs the thrombocytopenic patient died (exact binomial probability 0.037). The estimated attributable mortality was 19.5% (95% confidence interval 3.2-35.8), and the estimated odds ratio was 2.7 (95% confidence interval 1.02-7.10). Thrombocytopenic patients had comparable values for severity of illness scores between day of admission and day of thrombocytopenia, in contrast with control patients who had a statistically significant decrease in severity of illness scores during the same period. Thirty (83%) of the thrombocytopenic patients required transfusion of blood products, versus 21 (58%) control patients (paired chi2 test 4.92, P < 0.04). The estimated attributable transfusion requirement was 25% (95% confidence interval 5.4-44.6), and the estimated odds ratio was 1.52 (95 confidence interval 1.05-2.20). CONCLUSION: The present study suggests that thrombocytopenia of less than 50 x 109 platelets/l may be a marker for more severe illness and increased risk of death, rather than causative, because a true causal relationship is not established. Thrombocytopenia also leads to an excess of blood product consumption.