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Background The lack of reliable data on gastric emptying of solid food during labor has led to some discrepancies between current guidelines regarding fasting for solid food in the parturient. This prospective comparative study aimed to test the hypothesis that the gastric emptying fraction of a light meal would be reduced in parturients receiving epidural analgesia and with no labor analgesia compared with nonpregnant and pregnant women. Methods Ten subjects were enrolled and tested in each group: nonpregnant women, term pregnant women, parturients with no labor analgesia, and parturients with epidural labor analgesia. After a first ultrasound examination was performed to ensure an empty stomach, each subject ingested a light meal (125 g yogurt; 120 kcal) within 5 min. Then ultrasound measurements of the antral area were performed at 15, 60, 90, and 120 min. The fraction of gastric emptying at 90 min was calculated as [(antral area90 min / antral area15 min) – 1] × 100, and half-time to gastric emptying was also determined. For the Parturient–Epidural group, the test meal was ingested within the first hour after the induction of epidural analgesia. Results The median (interquartile range) fraction of gastric emptying at 90 min was 52% (46 to 61), 45% (31 to 56), 7% (5 to 10), and 31% (17 to 39) for nonpregnant women, pregnant women, parturients without labor analgesia, and parturients with labor epidural analgesia, respectively (P < 0.0001). The fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient–Epidural group than in the Nonpregnant and Pregnant Control groups. In addition, the fraction of gastric emptying at 90 min was statistically significant and lower in the Parturient–No-Epidural group than in the Parturient–Epidural group. Conclusions Gastric emptying in parturients after a light meal was delayed, and labor epidural analgesia seems not to worsen but facilitates gastric emptying. This should be taken into consideration when allowing women in labor to consume a light meal. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Pre-operative anxiety occurs in 18 to 60% of children undergoing surgery and results in poor outcomes. Nonpharmacological methods of distraction are effective in alleviating peri-operative anxiety. In our institution, ride-on electric cars (ride-on e-cars) are routinely used by children undergoing ambulatory surgery as a mean of nonpharmacological distraction.The aim of this study is to assess the effect of pre-operative distraction with ride-on e-cars on children's pre-operative anxiety when undergoing elective ambulatory surgery.This was a prospective, randomised, controlled, open-label study.The study was carried out from September 2019 to September 2021 in the ambulatory paediatric surgery unit of our teaching hospital, in Marseille, France.Children aged 2 to 10 years and weighing less than 35 kg undergoing elective ambulatory surgery were eligible. One hundred and fifteen children were included, 56 in the control group and 59 in the intervention group.Children in the control group were transported from the operating room (OR) waiting area to the OR using a trolley, while children in the intervention group used the ride-on e-cars, without pharmacological premedication or parental presence.The primary outcome was pre-operative anxiety at the end of the transport (prior going into the OR assessed by the modified Yale Preoperative Anxiety Score Short Form (mYPAS-SF). Secondary outcomes were the anxiety levels in children over time, as well as postoperative pain and agitation assessed with the Face Legs Activity Cry Consolability (FLACC) and Paediatric Anaesthesia Emergence Delirium (PAED) scales, respectively.The mYPAS-SF anxiety scores did not differ between the control group and the intervention group (39 ± 19 vs. 37 ± 21, P = 0.574). The secondary outcomes were similar between the two groups.Our randomised controlled trial showed that the use of ride-on e-cars did not alter pre-operative anxiety as compared with standard transport in children undergoing elective ambulatory surgery.Clinicaltrials.gov identifier: NCT03961581.

Inhaled halogenated anesthetics are responsible for half of operating room total greenhouse gas emissions. Sustainable anesthesia groups were set up in 4 Lyon, France, university hospitals (Hospices Civils de Lyon) in January 2018 and have supported a specific information campaign about the carbon footprint related to the use of inhaled halogenated anesthetics in June 2019. We aimed to assess whether implementing such information campaigns was associated with a decrease in the carbon footprint related to inhaled halogenated anesthetics.This retrospective cohort study was conducted from January 1, 2015, to February 29, 2020, in 4 hospitals of the Hospices Civils de Lyon in France. Information meetings on sustainable anesthesia practices were organized by sustainable anesthesia groups that were set up in January 2018. In addition, a specific information campaign about the carbon footprint related to inhaled halogenated anesthetics was conducted in June 2019; it was followed by a questionnaire to be completed online. The monthly purchase of sevoflurane, desflurane, and propofol was recorded, and the estimated monthly carbon footprint from desflurane- and sevoflurane-related perioperative emissions was calculated. The interrupted time-series data from January 2015 to February 2020 were analyzed by segmented regression, considering both interventions (setting up of the sustainable anesthesia groups and specific information campaign) in the analysis and adjusting for 2 confounding factors (seasonality of the data and number of general anesthesia uses).Among the 641 anesthesia providers from the study hospitals, 121 (19%) attended the information meetings about the carbon footprint of inhaled halogenated anesthetics, and 180 (28%) completed the questionnaire. The anesthetic activity from all 641 providers was considered in the analysis. After the sustainable anesthesia groups were set up, the carbon footprint of sevoflurane and desflurane started decreasing: the slope significantly changed (P.01) and became significantly negative, from -0.27 (95% confidence interval [CI], -1.08 to 0.54) tons.month-1 to -14.16 (95% CI, -16.67 to -11.65) tons.month-1. After the specific information campaign, the carbon footprint kept decreasing, with a slope of -7.58 (95% CI, -13.74 to -1.41) tons.month-1 (P = .02), which was not significantly different from the previous period (P = .07).The setup of the sustainable anesthesia groups was associated with a dramatic reduction in the carbon footprint related to halogenated anesthetics. These results should encourage health care institutions to undertake information campaigns toward anesthesia providers so that they also take into account the environmental impact in the choice of anesthetic drugs, in addition to the benefits for the patient and economic concerns.

Resume L’echographie antrale permet d’apprecier la vidange gastrique mais egalement d’analyser l’impact de la duree de jeune sur le risque de presenter un estomac plein avant une anesthesie generale. Les donnees recentes issues des etudes portant sur l’echographie de l’antre gastrique pourraient contribuer, a l’avenir, a une liberalisation des regles de jeune preoperatoire concernant, par exemple, la consommation de liquides clairs, de solutions de carbohydrates, d’une tasse de cafe ou de the au lait ou de chewing-gum, chez l’enfant et l’adulte en dehors de la grossesse, mais egalement chez la femme enceinte a terme en dehors du travail. Ces donnees pourraient egalement contribuer a autoriser la consommation d’un petit dejeuner leger jusqu’a quatre heures avant l’induction d’une anesthesie generale pour une chirurgie programmee en dehors du contexte obstetrical. Alors que les etudes issues de l’echographie gastrique peuvent confirmer le caractere securitaire de la consommation de liquides clairs ou de solutions de carbohydrates chez la parturiente, elles semblent decourager la consommation d’aliments solides au cours du travail obstetrical. Des etudes complementaires utilisant l’echographie antrale seront necessaires afin d’evaluer l’impact de la liberalisation des regles de jeune sur le risque de presenter un estomac plein avant une anesthesie generale, avant l’integration d’une telle liberalisation dans de futures recommandations.

Objective To assess the contribution of maternal blood detection of IGFBP-1 for the diagnosis of amniotic-fluid embolism in clinical daily practice. Design A retrospective multicentre cohort study. Setting Three tertiary care obstetric units in France. Sample Data of 86 women for whom amniotic-fluid embolism had been suspected and maternal serum detection of IGFBP-1 had been performed between 2011 and 2019 were analysed. Methods The criteria defined by the United Kingdom Obstetric Surveillance System (UKOSS) were used for the retrospective diagnosis of amniotic-fluid embolism. The more structured definition proposed by the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation (SMFM) was also used as secondary endpoint. Main outcome measures Agreements between biological and clinical assessments were tested. The performance of blood detection of IGFBP-1 for the diagnosis of amniotic-fluid embolism according to the UKOSS criteria, and to the SMFM definition, was also assessed. Results There was only slight agreement between clinical and laboratory diagnosis of amniotic-fluid embolism (Cohen's Kappa coefficient: 0.04). Blood detection of IGFBP-1 had a sensitivity of 16%, a specificity of 88%, a positive and a negative likelihood ratio of 1.3 and 0.95, respectively, and a positive and a negative predictive value of 58 and 50%, respectively, for the diagnosis of amniotic-fluid embolism based on the UKOSS criteria. The use of the more structured SMFM definition of amniotic-fluid embolism did not substantially change the results. Conclusion These results question the usefulness of blood detection of IGFBP-1 for the early diagnosis of amniotic-fluid embolism in daily clinical practice. Tweetable abstract This retrospective multicentre study questions the contribution of IGFBP-1 detection for the diagnosis of AFE.

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Resume Introduction Le present chapitre traite du bien etre maternel en termes d’hydratation et d’alimentation pendant le travail et de la prise en charge medicamenteuse de la douleur de l’accouchement. Methodes Les recommandations ont ete etablies a partir de l’analyse de la litterature et d’un consensus d’experts. Resultats La consommation de liquides clairs est autorisee pendant toute la duree du travail et en post-partum, sans limitation de volume, chez les patientes ayant un faible risque d’anesthesie generale (grade B). La consommation d’aliments solides n’est pas recommandee durant la phase active (avis d’experts [AE]). Il est recommande de privilegier l’analgesie locoregionale (ALR) pour prevenir l’inhalation bronchique (grade A). L’ALR est la methode d’analgesie demontree comme la plus sure et la plus efficace pour la mere (grade A) et pour l’enfant (grade B). Il est recommande d’informer et d’offrir aux femmes qui le souhaitent une technique d’ALR, de respecter leur choix qui peut evoluer (AE). Il est recommande de realiser une ALR « faibles doses » qui respecte le vecu de l’accouchement (grade A) et de l’entretenir au moyen d’une pompe d’auto-administration par la femme (grade A). Il n’y a pas lieu d’exiger une dilatation cervicale minimale pour proposer une ALR (grade A) ni d’interrompre l’analgesie peridurale faiblement dosee avant la phase d’expulsion (AE) ou pour un geste endo-uterin ou perineal (AE) ni d’administrer de facon systematique et preventive des fluides ou des vasopresseurs du simple fait de l’ALR faible dose (grade B), ni de recourir systematiquement aux ocytociques du seul fait de l’ALR (AE). Il est recommande de surveiller la pression arterielle et le rythme cardiaque fœtal toutes les 3 minutes apres l’induction et/ou chaque bolus > 10 mL puis toutes les heures (AE). Les postures de l’accouchement sont autorisees et doivent etre tracees et ne modifient pas la diffusion de l’ALR (grade C) (NP2). Il n’y a pas d’effet de l’ALR faiblement dosee sur la duree du travail obstetrical, ni sur le taux d’accouchements instrumentaux ou de cesarienne (NP1) ni d’effet deletere sur le fœtus ou le nouveau-ne (NP1). En cas de contre-indication a l’ALR ou dans l’attente de celle-ci, les alternatives medicamenteuses analgesiques (melange equimolaire oxygene-protoxyde d’azote ; nalbuphine et tramadol ; bloc honteux) peuvent etre proposees mais restent d’une efficacite mediocre a moderee et sont associees a des effets secondaires maternels et surtout neonataux (NP2). Les substances comme le remifentanil, la ketamine et les halogenes sont exclues de ces recommandations eu egard a leurs indications et effets secondaires majeurs. Conclusion Ces recommandations professionnelles etablissent a partir de la litterature et des avis des experts que, dans le cadre de l’accouchement normal, l’hydratation est autorisee pendant le travail et que l’analgesie locoregionale (peridurale ou rachianalgesie) a faibles doses et entretenues par PCEA conjugue la meilleure efficacite et securite.

INTRODUCTION The relationship between regurgitated and aspirated volume of clear fluids remains undetermined and may depend on anatomical factors and patient position. We aimed to assess whether head position (sniffing vs. extension position) affected this relationship in fresh human cadavers. We also determined the critical volume of water regurgitated that led to pulmonary aspiration of volume ≥ 0.8 mL kg-1 and ≥ 1.5 mL kg-1 for each head position. MATERIAL AND METHODS Six volumes of water (40, 80, 100, 120, 150, and 200 mL) were injected each twice, in a randomised order, at a flow rate of 20 mL per second, into the oesophagus of seven fresh human cadavers lying in the supine position on a non-tilted table, with the head in the sniffing position and in the extension position. Aspirated volume was measured in the trachea, blindly to the volume injected. RESULTS Overall, more than 85% of the regurgitated volume was aspirated into the trachea. The volume of aspirated water was significantly greater in the sniffing position than in the extension position. The cut-off volumes of water injected into the oesophagus leading to aspirated volume ≥ 0.8 mL kg-1 and ≥ 1.5 mL kg-1 were, respectively, 0.8 mL kg-1 and 1.5 mL kg-1 in the sniffing position, and 1.2 mL kg-1 and 1.8 mL kg-1 in the extension position. CONCLUSIONS These results confirm that most of the regurgitated clear fluid enters the trachea in humans lying in the supine position on a non-tilted table, especially when the head is in the sniffing position.

Objective The objective of these guidelines is to define for women at low obstetric risk modalities that respect the physiology of delivery and guarantee the quality and safety of maternal and newborn care. Methods These guidelines were made by a consensus of experts based on an analysis of the scientific literature and the French and international recommendations available on the subject. Results It is recommended to conduct a complete initial examination of the woman in labor at admission (Consensus agreement). The labor will be monitored using a partogram that is a useful traceability tool (Consensus agreement). A transvaginal examination may be offered every two to four hours during the first stage of labor and every hour during the second stage of labor or before if the patient requests it, or in case of a warning sign. It is recommended that if anesthesia is required, epidural or spinal anesthesia should be used to prevent bronchial inhalation (grade A). The consumption of clear fluids is permitted throughout labor in patients with a low risk of general anesthesia (grade B). It is recommended to carry out a "low dose" epidural analgesia that respects the experience of delivery (grade A). It is recommended to maintain the epidural analgesia through a woman's self-administration pump (grade A). It is recommended to give the woman the choice of continuous (by cardiotocography) or discontinuous (by cardiotocography or intermittent auscultation) monitoring if the conditions of maternity organization and the permanent availability of staff allow it and, after having informed the woman of the benefits and risks of each technique (Consensus agreement). In the active phase of the first stage of labor, the dilation rate is considered abnormal if it is less than 1cm/4h between 5 and 7 cm or less than 1cm/2h above 7cm (level of Evidence 2). It is then recommended to propose an amniotomy if the membranes are intact or an oxytocin administration if the membranes are already ruptured, and the uterine contractions considered insufficient (Consensus agreement). It is recommended not to start expulsive efforts as soon as complete dilation is identified, but to let the presentation of the fetus drop (grade A). It is recommended to inform the gynecologist-obstetrician in case of nonprogression of the fetus after two hours of complete dilation with sufficient uterine dynamics (Consensus agreement). It is recommended not to use abdominal expression (grade B). It is recommended to carry out preventive administration of oxytocin at 5 or 10 IU to prevent PPH after vaginal delivery (grade A). In the case of placental retention, it is recommended to perform a manual removal of the placenta (grade A). In the absence of bleeding, it should be performed 30 minutes but not more than 60 minutes after delivery (Consensus agreement). It is recommended to assess at birth the breathing or screaming, and tone of the newborn to quickly determine if resuscitation is required (Consensus agreement). If the parameters are satisfactory (breathing present, screaming frankly, and normal tonicity), it is recommended to propose to the mother that she immediately place the newborn skin-to-skin with her mother if she wishes, with a monitoring protocol (grade B). Delayed cord clamping is recommended beyond the first 30 seconds in neonates, not requiring resuscitation (grade C). It is recommended that the first oral dose (2 mg) of vitamin K (Consensus agreement) be given systematically within two hours of birth. Conclusion These guidelines allow women at low obstetric risk to benefit from a better quality of care and optimal safety conditions while respecting the physiology of delivery.

Resume Tout traitement qui peut modifier la perfusion placentaire, l’oxygenation fœtale ou agir directement sur le fœtus peut theoriquement modifier les outcomes fœtaux. Il est possible de predire les effets de l’anesthesie sur le pronostic fœtal si on tient compte de plusieurs marqueurs : Score d’Apgar, gazometrie detaillee (pH mais aussi reserve alcaline, lactates), scores comportementaux (Sarnat et NACS). Une acidose metabolique severe avec un score de Sarnat 3 est de mauvais pronostic neurologique. Des enregistrements EEG et IRM sont necessaires pour completer le pronostic. Pratiquement toutes les molecules d’anesthesie franchissent le placenta. Cependant, leurs effets neonataux sont modestes et sans consequences immediates. Seule des perfusions prolongees de propofol et de remifentanil peuvent affecter la vitalite fœtale immediate. Certaines techniques, en particulier la rachianesthesie, peuvent induire une baisse de la perfusion placentaire et donc une acidose metabolique chez le fœtus. Les vasopresseurs corrigent cette hypoperfusion. Parmi eux, seule l’ephedrine a un effet metabolique chez le fœtus. A tres forte dose, elle peut induire une acidose qui se corrigera rapidement apres la naissance. En soit, l’analgesie neuraxiale obstetricale comprenant des anesthesiques locaux a faible dose et des additifs divers (morphiniques, clonidine, dexmedetomidine) sont sans effet direct sur le pronostic fœtal. Si la pression arterielle maternelle est maintenue proche de 90 % des valeurs basales au cours d’une cesarienne, le pronostic fœtal n’est pas modifie par la technique d’anesthesie. L’injection de morphiniques en intrathecal peut provoquer une hypertonie uterine avec bradycardie fœtale, mais sans effet sur le pronostic fœtal. Une PCA intraveineuse aux morphiniques aux doses recommandees a peu d’effets neonataux. L’oxygenation maternelle et la bascule de la table operatoire a 15 ° n’ameliorent que rarement l’oxygenation fœtale.

Resume L’inhalation bronchique du contenu gastrique a ete identifiee comme l’une des principales causes de mortalite et de morbidite liees a l’anesthesie dans les pays developpes. L’utilisation de l’echographie antrale en temps reel est susceptible d’apporter une aide a l’anesthesiste pour l’evaluation du risque d’inhalation bronchique, dans le but de choisir la strategie anesthesique la plus appropriee. L’evaluation echographique preoperatoire du contenu gastrique pourrait etre proposee chez tous les patients devant beneficier d’une procedure chirurgicale en urgence. Les patients n’ayant pas respecte les regles de jeune ou pour lesquels la duree de jeune preoperatoire est douteuse, ainsi que les patients presentant des conditions preoperatoires susceptibles de ralentir la vidange gastrique (diabete, administration preoperatoire d’opioides et insuffisance renale chronique), pourraient egalement beneficier d’une evaluation echographique du contenu gastrique avant une procedure chirurgicale programmee. Enfin, l’echographie antrale pourrait avoir un interet en cas de procedure obstetricale a la fin de la grossesse ou en postpartum immediat. L’evaluation echographique du contenu gastrique peut donc avoir un interet pour l’orientation et l’individualisation de la strategie anesthesique. Toutefois, l’impact potentiel de l’integration de l’echographie antrale dans des algorithmes de decision clinique en pratique quotidienne sur l’incidence de l’inhalation bronchique et la morbi-mortalite perianesthesique reste a evaluer.

International audience; War is back in Europe. With all its horrific pictures and live videos.In its report issued on the 24th of March 2022, the World Health Organization (WHO) [1] states that the Ukrainian conflict has involved 18 million persons so far, with 3.4 million refugees in bordering countries and 6.4 million persons internally displaced (Fig. 1). In this report, 1,035 deaths and 1,650 civilian injuries were reported in Ukraine without any reported data from Russia.

We report a pediatric patient who underwent a central venous catheter (CVC) insertion and presented with a sudden protrusion of a guidewire from the neck 26 months later. The guidewire was extracted via femoral venotomy. A 5-cm portion of the guidewire adhering to the superior vena cava wall was left in place. We recommend always using a CVC checklist, inspecting the guidewire before and after insertion, and carefully examining the postinsertion radiographs. This checklist should be mandatory with every CVC insertion, including the perioperative period.

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Current paediatric anaesthetic fasting guidelines have recommended conservative fasting regimes for many years and have not altered much in the last decades. Recent publications have employed more liberal fasting regimes with no evidence of increased aspiration or regurgitation rates. In this first solely paediatric European Society of Anaesthesiology and Intensive Care (ESAIC) pre-operative fasting guideline, we aim to present aggregated and evidence-based summary recommendations to assist clinicians, healthcare providers, patients and parents. We identified six main topics for the literature search: studies comparing liberal with conservative regimens; impact of food composition; impact of comorbidity; the use of gastric ultrasound as a clinical tool; validation of gastric ultrasound for gastric content and gastric emptying studies; and early postoperative feeding. The literature search was performed by a professional librarian in collaboration with the ESAIC task force. Recommendations for reducing clear fluid fasting to 1 h, reducing breast milk fasting to 3 h, and allowing early postoperative feeding were the main results, with GRADE 1C or 1B evidence. The available evidence suggests that gastric ultrasound may be useful for clinical decision-making, and that allowing a 'light breakfast' may be well tolerated if the intake is well controlled. More research is needed in these areas as well as evaluation of how specific patient or treatment-related factors influence gastric emptying.

Objective To provide national guidelines for the management of women with severe pre-eclampsia. Design A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE(r)) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE(r) methodology. Results The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/−), 9 have a moderate level of evidence (GRADE 2+/−), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. Conclusions There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

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Background The relationship between gastric fluid volume, volume of fluid regurgitated, and aspirated fluid volume remains unclear. Using a life-like manikin suitable for a pulmonary aspiration model, we aimed to assess the relationship between regurgitated and aspirated clear fluid volumes, and to determine the minimal value of the volume of liquid regurgitated that may lead to pulmonary aspiration of fluid volume ≥ 0.8 mL kg-1 (around 60 mL) that is likely to cause lung injury. Methods Several volumes of water ranging from 30 to 150 mL were injected in a randomized order, at a flow rate of 20 mL per second, into the esophagus of a manikin lying in the supine position on a non-tilted table, with the manikin head in the extension or in the sniffing position. Aspirated volumes were measured in the manikin bronchi, by an investigator blinded to the volume injected. Aspiration was defined as positive when the volume of collected water was ≥ 60 mL for at least one of the five injections of each volume of water. Results The minimal volume of water injected into the esophagus for an aspirated volume ≥ 0.8 mL kg-1 was 85 mL in the sniffing position, and was 150 mL in the extension position. Conclusions These results suggest that the critical cut-off value of gastric fluid volume to be considered for the risk of significant pulmonary aspiration would be ≥ 85 mL (≥ 1 mL kg-1), in the sniffing position. These results should however be confirmed in further studies using other models.

We assessed the impact of raising the upper section of the bed, and patient positioning, on ultrasound assessment of gastric fluid contents. We performed ultrasound examinations in 25 subjects lying on their back, left and right sides at bed angles of 0°, 30°, 45° and 90°; this was carried out while the subjects were fasted, and repeated 10 min after drinking ≥ 50 ml water. After drinking, gastric contents were detected more frequently in the 45° semirecumbent position compared with the supine and 30° positions. The diagnostic performance of the Perlas qualitative grading scale to detect gastric fluid volume > 1.5 ml.kg-1 was improved at 45°, compared with 0° and 30° angles. The use of a composite ultrasound grading scale at a 45° angle was associated with the best performance, with a sensitivity and specificity of 82%. Antral cross-sectional area was significantly increased when measured in the right lateral position, but there was no effect of raising the bed. In conclusion, raising the upper section of the bed significantly affected qualitative assessment of gastric fluid contents. Further studies are required to determine the most appropriate composite ultrasound grading scale and bed angle for fast and reliable qualitative ultrasound detection of fluid volumes > 1.5 ml.kg-1 .

This study aimed to assess whether elevating the head of the bed to 45° was associated with sensitivity90% of the qualitative ultrasound assessment for the diagnosis of gastric fluid volume 1.5 ml.kgProspective randomized observer-blind crossover trial.Hospices Civils de Lyon, France.Healthy adult volunteers.Two separate study sessions in fasting volunteers: with and without head-of-bed elevation to 45°, in a randomized order. Each session consisted of three tests, each corresponding to a randomized and different volume of water (either 0, 50, 100, 150 or 200 ml); the same volumes were used in both sessions and in a randomized order. Gastric ultrasounds were performed three minutes after the ingestion of water by an investigator blinded to the volume ingested.Diagnostic performance of each approach for the diagnosis of gastric fluid volume 1.5 ml.kgTwenty volunteers were included, and 120 measurements were analyzed. The sensitivity of the qualitative assessment for the diagnosis of gastric fluid volume 1.5 ml.kgThe results suggest that qualitative examination of gastric antrum in the supine position with head-of-bed elevation to 45° can discriminate between low and high gastric fluid volume with high sensitivity, while neither the composite ultrasound scale nor the clinical algorithm improved the diagnostic performance of gastric ultrasound for the diagnosis of gastric fluid volume 1.5 ml.kg

Study objective Children with acute extremity fractures are commonly considered to be at risk of pulmonary aspiration of gastric contents during the induction of anesthesia. This study aimed to evaluate the proportion of such children with high-risk gastric contents using preoperative gastric ultrasound. Design Prospective observational cohort study. Setting Specialist pediatric center over a 30-month period. Patients Children undergoing surgery within 24 h of an acute extremity fracture. Interventions None. Measurements According to preoperative qualitative and quantitative ultrasound analysis of the antrum in the supine and right lateral decubitus positions, gastric contents were classified as high-risk (clear liquid with calculated gastric fluid volume > 0.8 mL.kg−1, thick liquid, or solid) or low-risk. Factors associated with high-risk gastric contents were identified by multivariable analysis. Main results Forty-one children (37%; 95% CI: 28–47) of the 110 studied (mean(SD) age: 10(3) years) presented with high-risk gastric contents, including 26 (24%; 95% CI: 16–33) with solids/thick liquid contents. Scanning in the supine position alone allowed a diagnosis of high-risk gastric contents in 23 children out of the 63 for whom right lateral decubitus positioning was unfeasible. Gastric contents remained undetermined in 41 children, including one with a non-contributory gastric US (antrum non-visualized). Proximal limb fractures (OR: 2.5; 95% CI: 1.0–6.2), preoperative administration of opioids (OR: 3.9; 95% CI: 1.1–13), and the absence of bowel sounds (OR: 8.0; 95% CI: 1.4–44) were associated with high-risk gastric contents. Performing surgery the day following the trauma was a protective factor (OR: 0.1; 95% CI: 0.0–0.6). No cases of pulmonary aspiration occurred. Conclusions At least one-third of children with an acute isolated extremity fracture had preoperative gastric contents identified as high risk for pulmonary aspiration. Although preoperative history can guide anesthetic strategy in this population, ultrasound allowed clear stratification of the risk of aspiration in most cases.

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have led to massive admissions to intensive care units (ICUs). An ultrasound examination of the thorax is widely performed on admission in these patients. The primary objective of our study was to assess the performance of the lung ultrasound score (LUS) on ICU admission to predict the 28-day mortality rate in patients with SARS-CoV-2. The secondary objective was to asses the performance of thoracic ultrasound and biological markers of cardiac injury to predict mortality. Methods This multicentre, retrospective, observational study was conducted in six ICUs of four university hospitals in France from 15 March to 3 May 2020. Patients admitted to ICUs because of SARS-CoV-2-related acute respiratory failure and those who received an LUS examination at admission were included. The area under the receiver-operating characteristics (ROC) curve was determined for the LUS score to predict the 28-day mortality rate. The same analysis was performed for the Simplified Acute Physiology Score, left ventricular ejection fraction, cardiac output, brain natriuretic peptide and ultra-sensitive troponin levels at admission. Results In 57 patients, the 28-day mortality rate was 21%. The area under the ROC curve of the LUS score value on ICU admission was 0.68 [95% CI 0.54–0.82; p = 0.05]. In non-intubated patients on ICU admission (n = 40), the area under the ROC curves was 0.84 [95% CI 0.70–0.97; p = 0.005]. The best cut-off of 22 corresponded to 85% specificity and 83% sensitivity. Conclusions LUS scores on ICU admission for SARS-CoV-2 did not efficiently predict the 28-day mortality rate. Performance was better for non-intubated patients at admission. Performance of biological cardiac markers may be equivalent to the LUS score. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01702-0.

Background Quality care during childbirth requires that health care providers have not only excellent skills but also appropriate and considerate attitudes and behavior. Few studies have examined the proportion of women in Western countries expressing dissatisfaction with such inappropriate or inconsiderate behavior. This study evaluated this proportion in a sample presumably representative of French maternity units. Methods This prospective multicenter study, using data from a selfadministered questionnaire, took place in 25 French maternity units during one week in September 2018. The primary outcome measure was mothers' self-reported dissatisfaction with blatantly inappropriate behavior (ie, inappropriate attitude, inadequate respect for privacy, insufficient gentleness of care, and/or inappropriate language) by health care workers in the delivery room. The secondary outcome was their self-reported dissatisfaction with these workers' inconsiderate behavior (ie, unclear and inappropriate information, insufficient participation in decision-making, or deficient consideration of pain). Results Of 803 potentially eligible women, 627 completed the questionnaire after childbirth; 5.62% (35/623, 95% CI: 3.94-7.73) reported dissatisfaction with blatantly inappropriate behaviors and 9.79% (61/623, 95% CI: 7.57-12.40) with inconsiderate behaviors. The main causes of dissatisfaction reported by women in this survey were the inadequate consideration of their pain and the failure to share decision-making. Conclusions Most of the women were satisfied with how health care workers behaved towards them in the delivery room. Nonetheless, health care staff must be aware of women's demands for greater consideration of their expressions of pain and of their voice in decisions.

Objective To provide national guidelines for the management of women with severe pre-eclampsia. Design A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Methods The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology. Results The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/−), 9 have a moderate level of evidence (GRADE 2+/−), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations. Conclusions There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Several societies have raised the risk of viral transmission of SARS-Cov-2 due to surgical smoke during laparoscopic procedures in infected patients. We propose to discuss this issue and to describe specific measures during laparoscopic procedures and a new homemade closed filtration system for smoke evacuation. Since the outbreak of COVID-19, performing a laparoscopy should meet multi-modal requirements. Surgical smoke evacuation device may be an effective tool in reducing exposure to surgical smoke and aerosols.

Coronavirus pandemic is widely changing our professional daily practice and preventive measures must be taken and taught. Before any planned gynaecological or obstetric surgery, specific technics to put on and safely remove personal protective equipment should be implemented in order to avoid any contamination for both patients and healthcare workers.

Pregnant women are at increased risk of hypoxaemia during general anaesthesia. Our aim was to determine the incidence and the risk factors that contribute to hypoxaemia in this setting.Every woman 18 yr or older who underwent a non-elective Caesarean section under general anaesthesia was eligible to participate in this multicentre observational study. The primary endpoint was the incidence of hypoxaemia defined as the SpODuring the study period, 895 women were prospectively included in 17 maternity hospitals, accounting for 79% of women who had general anaesthesia for non-elective Caesarean section. Maternal hypoxaemia was observed in 172 women (19%; confidence interval [CI], 17-22%). Risk factors associated with hypoxaemia in the multivariate analysis were difficult or failed intubation (adjusted odds ratio [aOR]=19.1 [8.6-42.7], P0.0001) and BMI35 kg mHypoxaemia during Caesarean sections was observed in 19% of women and was significantly associated with difficult or failed intubation. The use of propofol may protect against the occurrence of difficult intubation.

Purpose The relationship between lung ultrasound (LUS) and chest computed tomography (CT) scans in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia is not clearly defined. The primary objective of our study was to assess the performance of LUS in determining severity of SARS-CoV-2 pneumonia compared with chest CT scan. Secondary objectives were to test the association between LUS score and location of the patient, use of mechanical ventilation, and the pulse oximetry (SpO2)/fractional inspired oxygen (FiO2) ratio. Methods A multicentre observational study was performed between 15 March and 20 April 2020. Patients in the Emergency Department (ED) or Intensive Care Unit (ICU) with acute dyspnoea who were PCR positive for SARS-CoV-2, and who had LUS and chest CT performed within a 24-h period, were included. Results One hundred patients were included. LUS score was significantly associated with pneumonia severity assessed by chest CT and clinical features. The AUC of the ROC curve of the relationship of LUS versus chest CT for the assessment of severe SARS-CoV-2 pneumonia was 0.78 (CI 95% 0.68–0.87; p

Background The proportion of women with multiple sclerosis experiencing a relapse in the post-partum period after neuraxial labour analgesia or neuraxial anaesthesia remains uncertain. This study aimed to assess the association between neuraxial labour analgesia or neuraxial anaesthesia and the occurrence of relapse during the first three months post-partum. Methods In this retrospective cohort study, cases of women with a diagnosis of multiple sclerosis delivering between January 2010 and April 2015 were analysed. Demographic, anaesthetic and obstetric characteristics, occurrence and number of relapses in the year preceding pregnancy, during pregnancy, and the first three post-partum months, were recorded. Logistic regression analyses were performed for the identification of factors associated with the occurrence of post-partum relapse. Results A total of 118 deliveries in 104 parturients were included, these were 78 (66%) vaginal deliveries and 40 (34%) caesarean deliveries. Neuraxial analgesia was provided in 50 deliveries, and neuraxial anaesthesia in 46 deliveries; no neuraxial anaesthesia or analgesia was administered in remaining 22 deliveries. Post-partum relapse occurred in 31 women (26%). There was no association between obstetric or anaesthetic characteristics and post-partum relapse. Both the occurrence and number of relapses prior to and during pregnancy, and the time between last relapse and delivery, were significantly associated with post-partum relapse in univariate analysis. The occurrence of relapse within the year preceding the pregnancy was the sole independent factor associated with post-partum relapse. Conclusion Neuraxial procedures were not associated with increased rate of post-partum relapse; only disease activity prior to pregnancy was predictive of post-partum relapse.

Thromboembolic events may occur both during and after pregnancy Pregnancy in itself increases the thromboembolic risk, which is even greater during the postpartum period Due to additional coagulation changes induced by COVID-19 infection, this risk may even be greater