Dany Côté

A Comparison of Aprotinin and Lysine Analogues in High-Risk Cardiac Surgery

BACKGROUND Antifibrinolytic agents are commonly used during cardiac surgery to minimize bleeding and to reduce exposure to blood products. We sought to determine whether aprotinin was superior to either tranexamic acid or aminocaproic acid in decreasing massive postoperative bleeding and other clinically important consequences. METHODS In this multicenter, blinded trial, we randomly assigned 2331 high-risk cardiac surgical patients to one of three groups: 781 received aprotinin, 770 received tranexamic acid, and 780 received aminocaproic acid. The primary outcome was massive postoperative bleeding. Secondary outcomes included death from any cause at 30 days. RESULTS The trial was terminated early because of a higher rate of death in patients receiving aprotinin. A total of 74 patients (9.5%) in the aprotinin group had massive bleeding, as compared with 93 (12.1%) in the tranexamic acid group and 94 (12.1%) in the aminocaproic acid group (relative risk in the aprotinin group for both comparisons, 0.79; 95% confidence interval [CI], 0.59 to 1.05). At 30 days, the rate of death from any cause was 6.0% in the aprotinin group, as compared with 3.9% in the tranexamic acid group (relative risk, 1.55; 95% CI, 0.99 to 2.42) and 4.0% in the aminocaproic acid group (relative risk, 1.52; 95% CI, 0.98 to 2.36). The relative risk of death in the aprotinin group, as compared with that in both groups receiving lysine analogues, was 1.53 (95% CI, 1.06 to 2.22). CONCLUSIONS Despite the possibility of a modest reduction in the risk of massive bleeding, the strong and consistent negative mortality trend associated with aprotinin, as compared with the lysine analogues, precludes its use in high-risk cardiac surgery. (Current Controlled Trials number, ISRCTN15166455 [controlled-trials.com].).

Perioperative cardiorespiratory complications in adults with mediastinal mass: Incidence and risk factors

BackgroundPatients with a mediastinal mass are at risk for cardiorespiratory complications in the perioperative period. The authors’ objectives were to evaluate the incidence of life-threatening intraoperative cardiorespiratory and postoperative respiratory complications in adult patients and to study the usefulness of clinical signs and symptoms, radiologic evaluation, and pulmonary function tests in the determination of the perioperative risk. MethodsThe authors reviewed the investigation and treatment of adult patients presenting with anterior or middle mediastinal masses for surgery under anesthesia between January 1994 and July 2000. ResultsNinety-eight patients underwent 105 anesthetic cases. The incidences of intraoperative cardiorespiratory and postoperative respiratory complications were 4 in 105 and 11 in 105, respectively. No collapse of the airways occurred during anesthesia. However, a high incidence of early postoperative life-threatening respiratory complications was observed (7 in 105). In a multivariate logistic regression analysis model, perioperative complications were predicted by the occurrence of cardiorespiratory signs and symptoms at the initial presentation (odds ratio [OR], 6.2) and the presence of combined obstructive and restrictive patterns (mixed pulmonary syndrome) on pulmonary function tests (OR, 3.9). Intraoperative complications were associated with pericardial effusion on computed tomography scan (OR, 19.8). Postoperative respiratory complications were related to tracheal compression of more than 50% on preoperative computed tomography scan evaluation (OR, 7.4) and mixed pulmonary syndrome on pulmonary function tests (OR, 15.1). ConclusionObstruction of the airway in an adult with a mediastinal mass is a rare event in the intraoperative period. Nevertheless, caution should be observed for the occurrence of early postoperative life-threatening respiratory complications. Patient at high risk of perioperative complications can be identified by the occurrence of cardiopulmonary signs and symptoms at presentation, combined obstructive and restrictive pattern on pulmonary function tests, and computed tomography scan findings (tracheal compression > 50%, pericardial effusion, or both).

A Comparison of a Single or Triple Injection Technique for Ultrasound-guided Infraclavicular Block: A Prospective Randomized Controlled Study

BACKGROUND: Good success rates have been reported with ultrasound-guided infraclavicular block using one or multiple injections of local anesthetic. We hypothesized that a separate injection of local anesthetics on each cord enhances the onset of complete sensory block. We designed this prospective randomized study to compare the rate of complete sensory block using one or three injections of local anesthetic. METHODS: Patients scheduled for hand, wrist, or elbow surgery were included in this study. All blocks were performed under ultrasound guidance. In Group S (single injection), 30 mL of mepivacaine 1.5% was injected posterior to the axillary artery. In Group T (triple injections), 10 mL of mepivacaine 1.5% was injected on the posterior, medial, and lateral aspects of the axillary artery. Sensory block was evaluated every 3 min up to 30 min. The primary end point was the rate of complete sensory block at 15 min. RESULTS: Forty-nine and 51 patients were randomized in Groups S and T, respectively. The rate of complete sensory block was comparable at 15 min (Group S: 84%, Group T: 78%, P = 0.61) and at each time interval up to 30 min. There was no statistically significant difference in the rate of complications between the two groups. CONCLUSIONS: The success rate and the onset of complete sensory block after ultrasound-guided infraclavicular block are not enhanced by a triple injection of local anesthetic compared with a single injection posterior to the axillary artery.

Comparison of a single- or double-injection technique for ultrasound-guided supraclavicular block: a prospective, randomized, blinded controlled study.

Background Despite good success rates reported with ultrasound-guided supraclavicular block using 1 or multiple injections, no consensus exists on the best technique to use. We designed this study to test the hypothesis that a double-injection technique would hasten the onset of sensory block. Methods Adult patients undergoing hand, wrist, or elbow surgery were enrolled in this prospective double-blind randomized study. Blocks were performed under ultrasound guidance. In group S (single injection), 30 mL of mepivacaine 1.5% was injected at the junction of the subclavian artery and the first rib. In group D (double injection), 15 mL of the same solution was injected at the site described above, then 15 mL was injected in the most superficial portion of the lateral aspect of the cluster formed by the brachial plexus trunks and divisions. The primary end point was the rate of complete sensory block at 15 mins. Secondary end points were the rates of sensory, motor, and surgical blocks and procedure time. Results Fifty-one patients were randomized to each group. The rate of complete sensory block was similar at 15 mins (group S: 49% [95% confidence interval, 36%–62%], group D: 53% [95% confidence interval, 40%–66%]; P = 0.80) and at each time interval. The rates of complete motor block and surgical block success were similar between groups. The procedure time was shorter in group S (179 ± 104 vs 275 ± 137 secs; P < 0.01). Conclusions The double-injection technique offers no benefit over a single injection for the performance of an ultrasound-guided supraclavicular block.

Modified right-sided Broncho-Cath double lumen tube improves endobronchial positioning: a randomized study.

Objectif Une sonde double-lumiere gauche est recommandee lors de la ventilation pulmonaire selective pour la majorite des chirurgies thoraciques; toutefois, dans certaines indications, une sonde double-lumiere droite (SDL-D) peut etre requise. Il est fait etat de la malposition frequente des SDL-D. Nous proposons une modification de la SDL-D Broncho-Cath™ de Mallinckrodt qui consiste en une surface elargie de l’orifice lateral, et avons etudie l’impact de cette modification sur le bon positionnement de la SDL-D.ObjectiveA left-sided double lumen tube is recommended for one-lung ventilation for most thoracic surgeries, but for certain indications, a right-sided double lumen tube (R-DLT) may be mandatory. Frequent malposition of R-DLTs has been reported. We propose an innovative modification of Mallinckrodt’s Broncho-Cath™ R-DLT consisting of an enlarged area of the lateral orifice, and studied the impact of this modification on the adequacy of R-DLT positioning.MethodsEighty adult patients scheduled for elective thoracic surgery were randomized into two groups: standard Broncho-Cath™ R-DLT, or modified Broncho-Cath™ R-DLT. After induction of anesthesia, the R-DLT was positioned using a fibreoptic bronchoscope. The position of the R-DLT was assessed on three occasions: with the patient supine (T1), then immediately following the patient’s transfer to the lateral position (T2), and after repositioning of the tube, when needed, with the patient in lateral position (T3). A score ranging from 1 to 4 was accorded to the relative position of the right upper lobe (RUL) orifice in relation to the origin of the RUL bronchus.ResultsThe modified Broncho-Cath™ R-DLT was more frequently in an adequate position at T2: 77% vs 37% of patients (P = 0.0121), and easier to reposition at T3: 97% vs 74% of patients (P = 0.0109) in comparison to the standard Broncho-Cath™ R-DLT group.ConclusionThese data suggest the superiority of the modified Broncho-Cath™ R-DLT compared to a standard Broncho-Cath™ R-DLT for optimal R-DLT positioning to facilitate one-lung ventilation during thoracic surgery.RésuméObjectifUne sonde double-lumière gauche est recommandée lors de la ventilation pulmonaire sélective pour la majorité des chirurgies thoraciques; toutefois, dans certaines indications, une sonde double-lumière droite (SDL-D) peut être requise. Il est fait état de la malposition fréquente des SDL-D. Nous proposons une modification de la SDL-D Broncho-Cath™ de Mallinckrodt qui consiste en une surface élargie de l’orifice latéral, et avons étudié l’impact de cette modification sur le bon positionnement de la SDL-D.MéthodesQuatre-vingts patients adultes devant subir une chirurgie thoracique réglée ont été randomisés en deux groupes : SDL-D Broncho-Cath™ standard, ou SDL-D Broncho-Cath™ modifiée. Après induction de l’anesthésie, la SDL-D a été positionnée à l’aide d’un bronchoscope à fibres optiques. La position de la SDL-D a été évaluée trois fois : le patient sur le dos (T1), puis immédiatement après le transfert du patient en position latérale (T2), et après le repositionnement du tube, lorsque requis, le patient toujours en position latérale (T3). Une note de 1 à 4 a été donnée à la position relative de l’orifice du lobe supérieur droit (LSD) par rapport à l’origine de la bronche lobaire supérieure droite.RésultatsLa SDL-D Broncho-Cath™ modifiée fut plus fréquemment dans une position adéquate en T2: 77 % vs 37 % des patients (P = 0,0121) et fut plus facile à repositionner en T3 : 97 %vs74% des patients (P = 0,0109) par rapport au groupe SDL-D Broncho-Cath™ standard.ConclusionCes données suggèrent la supériorité de la SDL-D Broncho-Cath™ modifiée par rapport à la SDL-D Broncho-Cath™ standard pour un positionnement optimal de la SDL-D afin de faciliter la ventilation pulmonaire sélective pendant la chirurgie thoracique.

A Comparison of an Injection Cephalad or Caudad to the Division of the Sciatic Nerve for Ultrasound-Guided Popliteal Block: A Prospective Randomized Study

BACKGROUND The optimal site for local anesthetic injection during ultrasound-guided sciatic popliteal block remains controversial. METHODS Patients were randomized to receive 25 mL ropivacaine 0.75% around the sciatic nerve cephalad to the peroneal-tibial division in group A (n = 51) or caudad to the division in group B (n = 51). The sensory and motor blocks were evaluated every 5 minutes up to 30 minutes. RESULTS Rates of complete sensory block and surgical anesthesia were superior in group B (P < 0.0001). CONCLUSION The caudad technique provided better surgical anesthesia.

La sonde double-lumière droite modifiée Broncho-Cath™ améliore le positionnement endobronchique : une étude randomisée

Objectif Une sonde double-lumiere gauche est recommandee lors de la ventilation pulmonaire selective pour la majorite des chirurgies thoraciques; toutefois, dans certaines indications, une sonde double-lumiere droite (SDL-D) peut etre requise. Il est fait etat de la malposition frequente des SDL-D. Nous proposons une modification de la SDL-D Broncho-Cath™ de Mallinckrodt qui consiste en une surface elargie de l’orifice lateral, et avons etudie l’impact de cette modification sur le bon positionnement de la SDL-D.ObjectiveA left-sided double lumen tube is recommended for one-lung ventilation for most thoracic surgeries, but for certain indications, a right-sided double lumen tube (R-DLT) may be mandatory. Frequent malposition of R-DLTs has been reported. We propose an innovative modification of Mallinckrodt’s Broncho-Cath™ R-DLT consisting of an enlarged area of the lateral orifice, and studied the impact of this modification on the adequacy of R-DLT positioning.MethodsEighty adult patients scheduled for elective thoracic surgery were randomized into two groups: standard Broncho-Cath™ R-DLT, or modified Broncho-Cath™ R-DLT. After induction of anesthesia, the R-DLT was positioned using a fibreoptic bronchoscope. The position of the R-DLT was assessed on three occasions: with the patient supine (T1), then immediately following the patient’s transfer to the lateral position (T2), and after repositioning of the tube, when needed, with the patient in lateral position (T3). A score ranging from 1 to 4 was accorded to the relative position of the right upper lobe (RUL) orifice in relation to the origin of the RUL bronchus.ResultsThe modified Broncho-Cath™ R-DLT was more frequently in an adequate position at T2: 77% vs 37% of patients (P = 0.0121), and easier to reposition at T3: 97% vs 74% of patients (P = 0.0109) in comparison to the standard Broncho-Cath™ R-DLT group.ConclusionThese data suggest the superiority of the modified Broncho-Cath™ R-DLT compared to a standard Broncho-Cath™ R-DLT for optimal R-DLT positioning to facilitate one-lung ventilation during thoracic surgery.RésuméObjectifUne sonde double-lumière gauche est recommandée lors de la ventilation pulmonaire sélective pour la majorité des chirurgies thoraciques; toutefois, dans certaines indications, une sonde double-lumière droite (SDL-D) peut être requise. Il est fait état de la malposition fréquente des SDL-D. Nous proposons une modification de la SDL-D Broncho-Cath™ de Mallinckrodt qui consiste en une surface élargie de l’orifice latéral, et avons étudié l’impact de cette modification sur le bon positionnement de la SDL-D.MéthodesQuatre-vingts patients adultes devant subir une chirurgie thoracique réglée ont été randomisés en deux groupes : SDL-D Broncho-Cath™ standard, ou SDL-D Broncho-Cath™ modifiée. Après induction de l’anesthésie, la SDL-D a été positionnée à l’aide d’un bronchoscope à fibres optiques. La position de la SDL-D a été évaluée trois fois : le patient sur le dos (T1), puis immédiatement après le transfert du patient en position latérale (T2), et après le repositionnement du tube, lorsque requis, le patient toujours en position latérale (T3). Une note de 1 à 4 a été donnée à la position relative de l’orifice du lobe supérieur droit (LSD) par rapport à l’origine de la bronche lobaire supérieure droite.RésultatsLa SDL-D Broncho-Cath™ modifiée fut plus fréquemment dans une position adéquate en T2: 77 % vs 37 % des patients (P = 0,0121) et fut plus facile à repositionner en T3 : 97 %vs74% des patients (P = 0,0109) par rapport au groupe SDL-D Broncho-Cath™ standard.ConclusionCes données suggèrent la supériorité de la SDL-D Broncho-Cath™ modifiée par rapport à la SDL-D Broncho-Cath™ standard pour un positionnement optimal de la SDL-D afin de faciliter la ventilation pulmonaire sélective pendant la chirurgie thoracique.

The combination of inhaled nitric oxide and pulmonary artery balloon inflation improves oxygenation during whole-lung lavage.

We present a case in which the use of inhaled nitric oxide associated with temporary partial unilateral pulmonary artery occlusion further improved oxygenation during whole-lung lavage. This is the first case in the literature describing the simultaneous use of these two modalities.

Expert consensus for training in perioperative echocardiography in the province of Quebec.

PurposeEstablish an expert consensus for training in perioperative echocardiography in the province of Quebec.MethodsCardiac anesthesiologists practicing in the province of Quebec with expertise in echocardiography were involved in the development of a multicentre expert consensus on training in perioperative echocardiography. Guidelines for training in adult echocardiography, transesophageal echocardiography and perioperative echocardiography by the American Society of Echocardiography (ASE), the American College of Cardiology (ACC) and/or the Society of Cardiovascular Anesthesiologists (SCA) were reviewed.ResultsA basic, advanced and director level of expertise were identified for training in perioperative echocardiography. The total number of echocardiographic examinations to achieve each of these levels of expertise remains unchanged from the 2002 ASE-SCA guidelines. However, the recommended proportion of examinations performed personally is increased in the Quebec expert consensus for both the basic and the advanced level of training to ensure proficiency in echocardiography while providing anesthesia care to the patient. A level of autonomy in perioperative echocardiography is also identified in the basic level of training as defined in the Quebec expert consensus. Maintenance of competence, certification in the perioperative transesophageal echocardiography (PTE) examination and duration of training are outlined for each of the three levels of training in the Quebec expert consensus but are not part of the recent 2002 ASE-SCA guidelines.ConclusionAdequate perioperative echocardiographic training is an important aspect of cardiovascular anesthesia. The ACC, ASE and SCA guidelines for training in echocardiography were modified to reflect the expert consensus of anesthesiologists in the province of Quebec.RésuméObjectifÉtablir un consensus d’experts sur la formation en échocardiographie périopératoire au QuébecMéthodeDes anesthésiologistes cardiaques pratiquant au Québec et ayant une expertise en échocardiographie ont participé à l’élaboration d’un consensus multicentrique d’experts sur la formation en échocardiographie périopératoire. Les lignes directrices de la formation en échocardiographie chez l’adulte, en échocardiographie transœsophagienne et en échocardiographie périopératoire produites par l’American Society of Echocardiography (ASE), l’American College of Cardiology (ACC) et/ou la Society of Cardiovascular Anesthesiologists (SCA) ont été passées en revue.RésultatsUn niveau de compétence élémentaire, avancé et supérieur a été défini pour la formation en échocardiographie périopératoire. Le nombre total d’examens échocardiographiques à réaliser pour atteindre chacun des niveaux demeure le même depuis la parution des lignes directrices 2002 de l’ASE-SCA. Par contre, le nombre fait personnellement est plus élevé pour les niveaux élémentaire et avancé de la formation décrite par les experts québécois pour assurer le dévelopement de compétences sûres en échocardiographie tout en prodiguant l’anesthésie au patient. Un niveau d’autonomie en échocardiographie périopératoire est aussi défini par le consensus d’experts pour la formation élémentaire. Le maintien des compétences, l’examen d’accréditation et la durée de la formation en échocardiographie transœsophagienne périopératoire (ETP) sont définis pour chacun des trois niveaux de formation par les experts du Québec, mais ils ne font pas partie des récentes lignes directrices 2002 de l’ASE-SCA.ConclusionUne formation adéquate en échocardiographie périopératoire est importante en anesthésie cardiovasculaire. Les lignes directrices de l’ACC, l’ASE et la SCA pour la formation en échocardiographie ont été adaptées par le consensus d’anesthésiologistes experts du Québec.

Quality of positioning between the right DLT and the modified one

INTRODUCTION Double lumen tube (DLT) is frequently used for lung isolation in thoracic surgery. Because of its higher margins of safety (MoS) 1 left-DLT is often used as first choice. However, right-DLT is occasionally necessary. The argument against regular use of a R-DLT is the risk of Right Upper Lobe (RUL) atelectasis resulting from its lower MoS 2 and secondary hypoxemia. Some design’s improvements of the R-DLT have been proposed since 15 years 3-5 . We are proposing a homemade enlarging, almost 100%, of the size of the RUL opening (RULO). This study was designed to assess the impact of this modification on the success rate of R-DLT’s positioning.