Emmanuel Rineau

Implementing a blood management protocol during the entire perioperative period allows a reduction in transfusion rate in major orthopedic surgery: a before-after study.

Patient blood management (PBM) must be promoted in orthopedic surgery and relies on different strategies implemented during the entire perioperative period. Our aim was to assess whether the introduction of a pre‐, intra‐, and postoperative PBM protocol combining erythropoietin (EPO), ferric carboxymaltose (FCM), and tranexamic acid was effective in reducing perioperative transfusion and postoperative anemia.

Ferric carboxymaltose increases epoetin-α response and prevents iron deficiency before elective orthopaedic surgery

Mots-clés Aged [6], Drug Synergism [7], Erythropoietin/therapeutic use [8], Female [9], Ferric Compounds/therapeutic use [10], Hematinics/therapeutic use [11], Hemoglobins/metabolism [12], Humans [13], Iron/blood/deficiency [14], Male [15], Maltose/analogs & derivatives/therapeutic use [16], Middle Aged [17], Orthopedic Procedures/methods [18], Preoperative Care [19], Recombinant Proteins/therapeutic use [20], Surgical Procedures, Elective [21] URL de la notice http://okina.univ-angers.fr/publications/ua8251 [22] DOI 10.1093/bja/aeu245 [23] Lien vers le document http://dx.doi.org/10.1093/bja/aeu245 [23] Titre abrégé Br J Anaesth

Impact of preoperative continuous femoral blockades on morphine consumption and morphine side effects in hip-fracture patients: A randomized, placebo-controlled study.

BACKGROUND Upon arrival at the emergency department, hip-fracture pain relief is usually carried out via systemic opioids. Continuous nerve blocks are efficient in the postoperative period, but have not been evaluated preoperatively. This study compared the reduction in morphine consumption and related side effects of a continuous femoral block with a single shot block in hip-fracture patients. METHODS Hip-fracture patients admitted to the emergency department received a femoral nerve catheter, with a single lidocaine injection. They were then randomized to ropivacaine (group R) or saline continuous infusion (placebo, group P) in a double-blind manner. Morphine consumption and side effects were prospectively collected until the 24th postoperative hour. RESULTS Sixty patients were included and 55 analyzed. There were no significant differences between the 2 groups regarding fracture types, delay before surgery (median [Q1-Q3]: 21.3 [14.5-29.4] versus 20.8 [15.7-36.2] hours for groups R and P, respectively; P=0.87) and catheter duration (47.5 [39.8-52.4] versus 42.5 [32.1-50.5] hours, P=0.29). Total morphine consumption was not significantly decreased in group R (5 [0-14] versus 8 [4.5-11] mg, P=0.3) and pain scores were similar (mean±SD; VAS 29±15/100 versus 33±13, P=0.3). We observed a significant reduction in morphine adverse effects (31% versus 69% for groups R and P, respectively; P<0.01), mainly nausea (31% versus 59%, P=0.03). One morphine side effect could be avoided for every 5 patients treated. CONCLUSION Preoperative continuous femoral blockades using ropivacaine reduce morphine side effects (mainly nausea) in hip-fracture patients without reducing morphine consumption.

Iron is essential for living

Iron as an element is a double-edged sword, essential for living but also potentially toxic through the generation of oxidative stress. The recent study by Chen and colleagues in Critical Care reminds us of this elegantly. In a mouse model of acute lung injury, they showed that silencing hepcidin (the master regulator of iron metabolism) locally in airway epithelial cells aggravates lung injury by increasing the release of iron from alveolar macrophages, which in turn enhances pulmonary bacterial growth and reduces the macrophages’ killing properties. This work underscores that hepcidin acts not only systematically (as a hormone) but also locally for iron metabolism regulation. This opens areas of research for sepsis treatment but also for iron deficiency or anaemia treatment, since the local and systemic iron regulation appear to be independent.

Does IV Iron Induce Plasma Oxidative Stress in Critically Ill Patients? A Comparison With Healthy Volunteers.

Objective:To compare the oxidative stress induced by IV iron infusion in critically ill patients and in healthy volunteers. Design:Multicenter, interventional study. Setting:Two ICUs and one clinical research center. Subjects:Anemic critically ill patients treated with IV iron and healthy volunteers. Interventions:IV infusion of 100 mg of iron sucrose. Measurements and Main Results:Thirty-eight anemic patients (hemoglobin, median [interquartile range] = 8.4 g/dL [7.7–9.2]) (men, 25 [66%]; aged 68 yr [48–77]; Simplified Acute Physiology Score II, 48.5 [39–59]) and 39 healthy volunteers (men, 18 [46%]; aged 42.1 yr [29–50]) were included. Blood samples were drawn before (H0) and 2, 6, and 24 hours (H2, H6, and H24) after a 60-minute iron infusion for the determination of nontransferrin bound iron, markers of lipid peroxidation—8&agr;-isoprostanes, protein oxidation—advanced oxidized protein product, and glutathione reduced/oxidized. Iron infusion had no effect on hemodynamic parameter in patients and volunteers. At baseline, patients had much higher interleukin-6, C-reactive protein, and hepcidin levels. 8&agr;-isoprostanes was also higher in patients at baseline (8.5 pmol/L [6.5–12.9] vs 4.6 pmol/L [3.5–5.5]), but the area under the curve above baseline from H0 to H6 was not different (p = 0.38). Neither was it for advanced oxidized protein product and nontransferrin bound iron. The area under the curve above baseline from H0 to H6 (glutathione reduced/oxidized) was lower in volunteers (p = 0.009). Eight patients had a second set of dosages (after the fourth iron infusion), showing higher increase in 8&agr;-isoprostanes. Conclusions:In our observation, IV iron infusion does not induce more nontransferrin bound iron, lipid, or protein oxidation in patients compared with volunteers, despite higher inflammation, oxidative stress, and hepcidin levels and lower antioxidant at baseline. In contrary, iron induces a greater decrease in antioxidant, compatible with higher oxidative stress in volunteers than in critically ill patients.

The STOP-BANG questionnaire and the risk of perioperative respiratory complications in urgent surgery patients: A prospective, observational study

INTRODUCTION The STOP-BANG (SB) questionnaire, a tool originally proposed for identifying patients at risk of obstructive sleep apnoea, may also identify patients at increased risk of perioperative complications (when>3). Perioperative complications, including respiratory ones, are more frequent in emergency surgery. This study aimed at evaluating whether the SB is predictive of perioperative respiratory complications in urgent surgery. METHODS Consecutive adult patients admitted for an urgent surgery under general anaesthesia were included. The STOP-BANG questionnaire was completed before anaesthesia. Perioperative respiratory complications were prospectively recorded during surgery and in the postoperative care unit (PACU). RESULTS One hundred and eighty-nine patients were included (women 46%, median age 60 [43-78] years old) of which 104 (55%) were SB+. Diabetes mellitus and arrhythmia were more frequent in the SB+ patients than in SB-. The ASA class was higher in SB+ patients compared with SB-, but type and duration of surgery were statistically similar. The incidence of respiratory complications was higher in SB+ patients both during surgery (21% versus 6%, P<0.002) and in the PACU (57% versus 34%, P=0.0015). Furthermore, SB+ patients had a prolonged length of hospital stay (6 [3-12] versus 4 [2-7] days, P=0.0002). In a multivariate analysis, the STOP-BANG score was independently associated with respiratory complications (OR [CI 95%]=1.44 [1.03-2.03], P=0.03). CONCLUSIONS An elevated STOP-BANG score (≥ 3) is associated with an increased risk of perioperative respiratory complications and with prolonged length of stay in urgent surgery patients.

Iron deficiency without anemia is responsible for decreased left ventricular function and reduced mitochondrial complex I activity in a mouse model

BACKGROUND Iron deficiency (ID), with or without anemia, is frequent in heart failure patients, and iron supplementation improves patient condition. However, the link between ID (independently of anemia) and cardiac function is poorly understood, but could be explained by an impaired mitochondrial metabolism. Our aim was to explore this hypothesis in a mouse model. METHODS AND RESULTS We developed a mouse model of ID without anemia, using a blood withdrawal followed by 3-weeks low iron diet. ID was confirmed by low spleen, liver and heart iron contents and the repression of HAMP gene coding for hepcidin. ID was corrected by a single ferric carboxymaltose (FCM) injection (ID + FCM mice). Hemoglobin levels were similar in ID, ID + FCM and control mice. ID mice had impaired physical performances and left ventricular function (echocardiography). Mitochondrial complex I activity of cardiomyocytes was significantly decreased in ID mice, but not complexes II, III and IV activities. ID + FCM mice had improved physical performance, cardiac function and complex I activity compared to ID mice. Using BN-PAGE, we did not observe complex I disassembly, but a reduced quantity of the whole enzyme complex I in ID mice, that was restored in ID + FCM mice. CONCLUSIONS ID, independently of anemia, is responsible for a decreased left ventricular function, through a reduction in mitochondrial complex I activity, probably secondary to a decrease in complex I quantity. These abnormalities are reversed after iron treatment, and may explain, at least in part, the benefit of iron supplementation in heart failure patients with ID.

Anemia of the Critically Ill Patient: Pathophysiology, Lessons from Animal Models

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1789 Abstract Children with intestinal failure are often dependent on long-term central venous catheters for delivery of all or a portion of their fluid and caloric requirements. Unfortunately, they are at high risk for catheter-associated complications, most commonly infection. Catheterrelated bloodstream infections (CRBSI) can be difficult to treat and can lead to systemic sepsis and critical illness in this patient population. This chapter discusses the role for ethanol lock therapy (ELT) in both the prevention and treatment of CRBSI in children with intestinal failure. The safety and efficacy of this therapy is discussed and the details for use in the pediatric population are provided.