C. Lejus

Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical-ICU head-trauma patients.

Background Early-onset ventilator associated pneumonia (EOVAP) are frequent in head-trauma patients, but specific risk factors are poorly studied in this population. Methods We conducted a retrospective cohort study in a surgical intensive care unit. Consecutive severe head-trauma patients admitted from January 2000 to December 2002 were studied. Microorganisms, and risks factors for EOVAP were analyzed. Results During the 3-year period, 161 patients were studied; 21.1% of them developed an EOVAP. On univariate analysis 6 variables were associated with EOVAP: early enteral feeding, barbiturate use, immunosuppression, mean Simplified Acute Physiology Score 2, acute respiratory distress syndrome, and initial neurosurgery procedures. On multivariate analysis, enteral feeding >2000 Kcal before day 5 [odds ratio (OR): 0.33, 95% confidence interval (CI): 0.21-0.85] and initial neurosurgical procedure (OR: 0.36, 95% CI: 0.15-0.89) remained protective factors for EOVAP, whereas immunosuppression (OR: 7.15, 95% CI: 1.66-30.73) and barbiturate use (OR: 2.68, 95% CI: 1.06-6.80) remained risk factors for EOVAP. EOVAP was also significantly associated with a longer duration of mechanical ventilation (14.0 vs. 11.0 d, P=0.024), and a longer sedation duration (8.3 vs. 5.8 d P=0.005). Methicillin-susceptible Staphylococcus aureus was the most common pathogen involved in EOVAP (46%). Conclusions We demonstrate for the first time that early enteral feeding is a protective factor for EOVAP, and this result could have clinical implications for the prevention of EOVAP after traumatic brain injury. This study also confirms that barbiturate use is an important risk factor of EOVAP whereas Methicillin-susceptible S. aureus was found to be the main pathogen involved in EOVAP.

CpG-ODN and MPLA Prevent Mortality in a Murine Model of Post-Hemorrhage-Staphyloccocus aureus Pneumonia

Infections are the most frequent cause of complications in trauma patients. Post-traumatic immune suppression (IS) exposes patients to pneumonia (PN). The main pathogen involved in PN is Methicillin Susceptible Staphylococcus aureus (MSSA). Dendritic cells () may be centrally involved in the IS. We assessed the consequences of hemorrhage on pneumonia outcomes and investigated its consequences on DCs functions. A murine model of hemorrhagic shock with a subsequent MSSA pneumonia was used. Hemorrhage decreased the survival rate of infected mice, increased systemic dissemination of sepsis and worsened inflammatory lung lesions. The mRNA expression of Tumor Necrosis Factor-alpha (TNF-α), Interferon-beta (IFN-β) and Interleukin (IL)-12p40 were mitigated for hemorrhaged-mice. The effects of hemorrhage on subsequent PN were apparent on the pDCs phenotype (reduced MHC class II, CD80, and CD86 molecule membrane expression). In addition, hemorrhage dramatically decreased CD8+ cDCs- and CD8- cDCs-induced allogeneic T-cell proliferation during PN compared with mice that did not undergo hemorrhage. In conclusion, hemorrhage increased morbidity and mortality associated with PN; induced severe phenotypic disturbances of the pDCs subset and functional alterations of the cDCs subset. After hemorrhage, a preventive treatment with CpG-ODN or Monophosphoryl Lipid A increased transcriptional activity in DCs (TNF-α, IFN-β and IL-12p40) and decreased mortality of post-hemorrhage MSSA pneumonia.

Airtraq laryngoscope for intubation in Treacher Collins syndrome.

Implications. New York: McGraw-Hill, 2006: 87–88. 3 Butler M, Hayes B, Hathaway M et al. Specific genetic diseases at risk for sedation ⁄ anesthesia complications. Anesth Analg 2000; 91: 837–855. 4 Sun D, Warriner C, Parsons D et al. The GlideScope Video Laryngoscope: randomized clinical trial in 200 patients. Br J Anaesth 2005; 94: 381–384. 5 Lai H, Chen I, Chen A et al. The use of the GlideScope for tracheal intubation in patients with ankylosing spondylitis. Br J Anaesth 2006; 97: 419–422.

Postoperative epidural analgesia with bupivacaine and fentanyl: hourly pain assessment in 348 paediatric cases

Background: The objective of this prospective study was the evaluation of the analgesia provided by an epidural infusion of bupivacaine and fentanyl after different types of surgery in children.

Inhalation induction using sevoflurane in children: the single‐breath vital capacity technique compared to the tidal volume technique*

The single‐breath vital capacity technique is suitable for inhalation induction of anaesthesia, using sevoflurane in children aged > 5 years. The purpose of this randomised trial was to compare the single breath vital capacity technique with the conventional tidal volume technique. Seventy‐ three ASA 1 or 2 children were instructed during the pre‐operative visit in the vital capacity technique. The main criterion measured was time to loss of the eyelash reflex. Induction was performed using a circle‐absorber breathing circuit primed with sevoflurane 7% in 50% nitrous oxide/oxygen with 6 l.min−1 fresh gas flow. Time required for induction, haemodynamic changes, airway tolerance and side‐effects were recorded. The childrens opinion on the technique used was scored using a visual analogue scale (0–100) and a Smiley scale (0–10). The time to loss of the eyelash reflex was found to be reduced in the vital capacity group compared to the tidal volume group. The time to central myosis, to achieve bispectral index values 60 and 40, haemodynamic changes, respiratory events and side‐effect incidences were similar in both groups. However, we found that the vital capacity technique was preferred by the children to the tidal volume technique.

Is haemostasis biological screening always useful before performing a neuraxial blockade in children

Background: Because of the lack of controlled studies, there is no consensus of opinion about the practice of routine haemostasis tests before neuraxial blockade in children. The purpose of this study was to compare the influence of two different strategies of coagulation evaluation on the incidence of diagnosed coagulopathies leading to a modification of the preoperative or anaesthetic management in children who were scheduled for caudal, epidural or intrathecal block.

Effects of perioperative intravenous low dose of ketamine on postoperative analgesia in children

Background and objective Low dose of ketamine reduces postoperative pain and opioid consumption in adult studies. However, there are only a few data with controversial results in the paediatric population. The aim of this randomized controlled trial was to evaluate the use of low doses of intravenous ketamine on postoperative pain in children after surgery on the lower part of the body. Methods Thirty-seven children with ASA 1 or 2 from 6 to 60 months of age, undergoing scheduled surgery, were prospectively enrolled in a double blind sequential trial using a triangular test, with analysis every 10 patients treated. The children were randomly assigned to intravenously receive saline or 0.15 mg kg−1 ketamine before surgery, followed by a continuous infusion of 1.4 μg kg−1 min−1 over 24 h. After sevoflurane induction and tracheal intubation, a caudal anaesthesia was performed in all children (1 ml kg−1 of bupivacaine 0.25% with epinephrine). The postoperative analgesic technique was standardized with intravenous paracetamol 15 mg kg−1 6 h−1, rectal morniflumate (20 mg kg−1 12 h−1) and intravenous nalbuphine infusion 1.2 mg kg−1 24 h−1 for 24 h. The Childrens Hospital of Eastern Ontario Pain Scale (CHEOPS) scores, additional bolus of nalbuphine (if CHEOPS >7) and side effects were recorded from eye opening every 2 h over 24 h. The primary endpoint was the CHEOPS area under the curve. Results There was no difference in terms of additional bolus of nalbuphine as well as CHEOPS score area under the curve between groups, that is, 76 ± 10 in the ketamine group versus 74 ± 7 in the control group. No psychomimetic side effects were noted. Conclusion The study failed to show any evidence of benefit of ketamine to improve analgesia in children when given in addition to a multimodal analgesic therapy with paracetamol, a NSAID and an opiate.

Development and validation of a risk score to predict the probability of postoperative vomiting in pediatric patients: the VPOP score

Few data are available in the literature on risk factors for postoperative vomiting (POV) in children.

A preoperative stay in an intensive care unit is associated with an increased risk of surgical site infection in neonates

BACKGROUND Neonates are considered as immunologically immature. There are no specific guidelines for surgical antibiotic prophylaxis in this population since data concerning the risk factors for surgical site infection (SSI) are lacking. METHODS A 40-month retrospective single-center study that included all consecutive neonates undergoing surgery was performed. The variables that could influence the rate of SSI were analyzed by multivariate analysis in order to determine the independent risk factors for SSI. RESULTS The survey included 286 neonates (91 F/195 M). Median age, term, and weight were 10 (0-19) days, 38 (37-39) weeks, 3 (2.7-3.5) kg, respectively. Sixteen percent of the neonates were premature. Surgery was mostly abdominal (71%). Prophylactic antibiotic was given in 66.4% of the cases and was highly variable (amoxicillin-clavulanate 20.3%, first generation cephalosporin 26.2%, second generation cephalosporin 11.9%, imidazole derivatives 13.6%, aminoglycosides 12.6%, vancomycin 0.7%, and ticarcillin-clavulanate 3.1%). The rate of SSI was 3.8%. Only two variables were identified as independent risk factors for SSI: gestational age OR: 0.821 (0.690-0.977) and preoperative hospitalization in an intensive care unit OR: 8.433 (1.031-69.005). CONCLUSION Preoperative stay in an intensive care unit and, to a lesser degree, low gestational age are associated with an increased SSI rate.

Preoperative moderate renal impairment is an independent risk factor of transfusion in elderly patients undergoing hip fracture surgery and receiving low-molecular-weight heparin for thromboprophylaxis ☆,☆☆,★

STUDY OBJECTIVE To define the risk factors of allogeneic erythrocyte transfusion in patients older than 65 years of age who underwent hip fracture surgery. DESIGN Retrospective, single-center study. SETTING Orthopedic unit of a university hospital. MEASUREMENTS The records of 413 consecutive patients undergoing hip fracture surgery over a 12-month period and receiving low-molecular-weight heparin (LMWH) for thromboprophylaxis were retrospectively reviewed. Preoperative independent predictors of transfusion were determined by multivariate analysis, from which a model of individual probability of transfusion was derived using creatinine clearance calculated by Cockroft-Gault (CG) and the Modification of Diet in Renal Disease (MDRD) formulas. MAIN RESULTS Using the CG and MDRD formulas, 56.9% and 50.1% of patients had moderate renal impairment that was an independent factor associated with transfusion, with adjusted odds ratios of 2.44 (1.49 - 4.02) and 2.35 (1.32 - 4.18), respectively. Other factors were fracture with trochanteric extension, preoperative hemoglobin (Hb) < 12 g/dL, and weight. The observed transfusion rate and probability of transfusion calculated with the regression logistic model were well correlated: y = 0.9534x + 0.0287, P < 0.0001, Pearson coefficient 0.988, goodness of fit, χ(2), P = 1 with CG; y = 0.9197x + 0.0504, P < 0.0001, Pearson coefficient 0.956, goodness of fit, χ(2), P = 1 with MDRD). CONCLUSION This predictive model may be useful to identify those elderly patients undergoing hip fracture repair who are at risk of blood transfusion.