Fernande Lois

Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management

BACKGROUND:Dynamic variables predict fluid responsiveness and may improve fluid management during surgery. We investigated whether displaying the variability in the pulse oximeter plethysmogram (pleth variability index; PVI) would guide intraoperative fluid management and improve circulation as assessed by lactate levels. METHODS:Eighty-two patients scheduled for major abdominal surgery were randomized into 2 groups to compare intraoperative PVI-directed fluid management (PVI group) versus standard care (control group). After the induction of general anesthesia, the PVI group received a 500-mL crystalloid bolus and a crystalloid infusion of 2 mL · kg−1 · h−1. Colloids of 250 mL were administered if the PVI was >13% Vasoactive drug support was given to maintain the mean arterial blood pressure above 65 mm Hg. In the control group, an infusion of 500 mL of crystalloids was followed by fluid management on the basis of fluid challenges and their effects on mean arterial blood and central venous pressure. Perioperative lactate levels, hemodynamic data, and postoperative complications were recorded prospectively. RESULTS:Intraoperative crystalloids and total volume infused were significantly lower in the goal-directed PVI group. Lactate levels were significantly lower in the PVI group during surgery and 48 hours after surgery (P < 0.05). CONCLUSIONS:PVI-based goal-directed fluid management reduced the volume of intraoperative fluid infused and reduced intraoperative and postoperative lactate levels.

Something new about ketamine for pediatric anesthesia

Purpose of review This review discusses the place of the old anesthetic ketamine in pediatric anesthesia. Recent findings Despite the availability of modern alternatives, ketamine remains a frequently used drug particularly for anesthesia in high-risk children and for procedures outside the operating room. In adult patients undergoing surgery, a renewed interest in this drug is noted. It is the consequence of recent demonstrations of the following effects. First, ketamine is highly effective against surgery and opiate-induced hyperalgesia. Second, it has original antiproinflammatory properties. In other words, it promotes self-limitation of the inflammatory response that follows surgery. In the pediatric population, these benefits wait to be confirmed. Finally, questions arise about the safety of ketamine anesthesia. Ketamine is a potent proapoptotic drug. In rodents treated during the critical period for central nervous system development, long-term behavioral deficits were noted after an anesthetic dose of ketamine. The exact consequences of these proapoptotic properties on human brain tissue development have to be exactly determined and are still debatable. Summary Ketamine has not yet revealed all its interactions in humans. Recent discoveries indicate interesting properties on the one hand and potentially deleterious effects on the other.

The Concept of Titration can be Transposed to Fluid Management. But does is Change the Volumes? Randomised Trial on Pleth Variability Index During Fast-Track Colonic Surgery

BACKGROUND The concept of drug titration emerged recently for intraoperative fluid administration during Fast-Track colonic surgery to avoid hypovolemia as well as excessive crystalloid administration. The Pleth Variability Index (PVI) is an oximeter-derived parameter. It allows a continuous monitoring of the respiratory variation of the perfusion index. OBJECTIVE To investigate if applying the concept of fluid titration with PVI-guided colloid administration conjointly with restricted crystalloids administration changes the amount of fluid administered. DESIGN, SETTINGS AND PATIENTS: Twenty one ASA 2 patients scheduled for Fast-Track colonic surgery were randomized in two groups: the PVI-guided the fluid management group and the the control group. INTERVENTION AND MAIN OUTCOME MEASURES After the induction of general anesthesia, the PVI group received a 10 mL.kg- 1.h-1 infusion of crystalloid during the first hour, reduced to 2 mL.kg-1.h-1 thereafter. Colloids 250 mL were administered if necessary to maintain a PVI value of 10 to 13%. In the control group, a 10 mL.kg-1.h-1 infusion of crystalloid during the first hour was followed by a 5 mL.kg-1.h-1 infusion. Boluses of 250 mL of colloids were administered if required to maintain the mean arterial pressure above 65 mmHg. RESULTS Intraoperative crystalloids infused volume were significantly lower in the PVI group (925+/-262 mL vs 1129+/- 160 mL; P=0.04). In contrast, the infused amounts of colloids was higher in the PVI group (725+/-521 mL vs 250+/-224 mL; P=0.01). Interestingly, total fluid amount infused intra- ant postoperatively were similar between the groups (1650+/- 807 mL vs 1379+/-186 mL; P=0.21). CONCLUSION PVI-guided fluid management in Fast-Track colonic surgery is not necessarily associated with different total volume infused.

A comparison of intubation conditions and time-course of action with rocuronium and mivacurium for day case anaesthesia.

Background and objective: To compare intubation conditions and time‐course of action of rocuronium and mivacurium for day case anaesthesia. Methods: Fifty ASA I or II patients were enrolled. Anaesthesia was induced with propofol using a target controlled infusion system (target 6–8 &mgr;g mL−1) and sufentanil (0.25 &mgr;g kg−1). It was maintained with propofol (target 3.5–4.5 &mgr;g mL−1) and 50% nitrous oxide in oxygen. Muscle relaxation was achieved with either mivacurium (0.15 mg kg−1) or rocuronium (0.3 mg kg−1). Neuromuscular transmission was monitored and recorded continuously by acceleromyography using a TOF‐WATCH SX (BiometerTM/; Denmark) with supramaximal train‐of‐four stimulation of the ulnar nerve. Tracheal intubation was carried out by an experienced anaesthetist blinded to the type of the muscle relaxant. Intubation conditions were evaluated according to a standard scheme (ease of laryngoscopy, position of vocal cords, airway reaction and limb movements). Results: Intubation conditions were good or excellent for both mivacurium 0.15 mg kg−1 (good = 8%; excellent = 92%) and rocuronium 0.3 mg kg−1 (excellent = 100%). Times to maximum blockade and clinical duration were not different. Conclusions: There is no significant difference between mivacurium and rocuronium concerning the onset and the recovery of muscle relaxation. Rocuronium is an alternative to mivacurium for short procedures, without the risk of unexpected prolonged relaxation due to a possible defect in plasma cholinesterase.

In vivo optical spectroscopy monitoring in a new model of muscular compartment syndrome

BACKGROUND Muscular compartment syndrome (MCS) is a rare but serious postoperative complication. In vivo optical spectroscopy (INVOS) monitors continuously and non-invasively regional oxygen saturation (rSO(2)), and could predict the development of MCS. METHODS In 10 healthy volunteers, we inflated a tourniquet to the mean arterial pressure to produce slight venous congestion and arterial hypoperfusion. Comparisons were made between the relative reduction in rSO(2) with baseline (deltaINVOS) and the time to observe motor nerve block (with non-invasive electromyography). Neurological symptoms, pain, and invasive intracompartmental pressure (ICP) were assessed. RESULTS In the eight volunteers completing the protocol, we observed a profound motor nerve conduction block, immediately reversible. Baseline values were: [mean (sd)] INVOS: 73.3 (8.9)% and ICP: 16.9 (8.6) mm Hg. At the time of the block, values were: INVOS: 46.4 (10.9)%, deltaINVOS: 28.7 (10.6)%, and ICP: 70.0 (5.5) mm Hg. The time to reach the block was 33.0 (10.9) min, and to a deltaINVOS>10%: 27.4 (10.4) min. Receiver-operating characteristic curves demonstrated a similar accuracy of ICP and INVOS to predict the occurrence of the block. Twenty minutes with a deltaINVOS>10% or ICP>30 mm Hg were associated with a sensitivity and a specificity of 95% and 70%; or 91% and 65%, respectively. CONCLUSIONS We have developed a model of acute immediately reversible MCS. Monitoring using the INVOS technology is as accurate as measurement of ICP, and could be a useful tool to prevent development of intraoperative MCS.

Réhabilitation rapide (fast-track) en chirurgie colorectale : étude comparative avec la prise en charge conventionnelle (369)

Objectifs L’etude avait pour but de comparer les resultats de la prise en charge selon un protocole de rehabilitation rapide (fast-track) avec ceux d’une prise en charge traditionnelle en chirurgie colorectale. Les parametres analyses etaient la duree d’hospitalisation, la morbidite postoperatoire et la satisfaction des patients. Materiel et Methode Deux cents quarante-trois patients consecutifs ayant eu une chirurgie colorectale ont ete inclus. Le groupe fast-track (FT) (124 patients) a ete compare a une cohorte retrospective de 119 patients (groupe controle - CONT), ayant ete traites de facon conventionnelle. Les criteres d’exclusion etaient les suivants : score ASA IV, score AFC ≥ 3, chirurgie pour pathologie rectale ou necessitant la confection d’une stomie. La voie d’abord etait preferentiellement laparoscopique dans les deux groupes (96,8 % pour le group FT et 91,8 % pour le group CONT) ( p = ns). Une analyse multivariee par regression logistique a ete realisee pour identifier les facteurs influencant la duree d’hospitalisation et le taux de complication. Le niveau de satisfaction des patients a ete evalue au moyen d’un questionnaire specifique. Resultats La mortalite etait de 0 % dans le groupe FT et de 0,8 % dans le groupe CONT ( p = ns). La morbidite etait respectivement de 30,6 % (FT) et de 38,6 % (CONT) ( p = ns). La duree mediane d’hospitalisation a ete de 3 jours [2-16] dans le groupe FT et de 6 jours [3-29] dans le groupe CONT ( p 0,001). Le taux d’admission dans le service des urgences apres FT etaient de 16,9 % et de 7,6 % pour le groupe CONT ( p 0,05) ; le taux de re-hopitalisation ne differait pas de maniere significative (8 % vs 4,2 %, p = ns). La satisfaction globale des patients etait plus elevee dans le groupe FT. L’analyse multivariee a mis en evidence trois facteurs pronostiques independants favorable pour la duree d’hospitalisation, a savoir un âge p = 0,001), l’approche laparoscopique ( p = 0,001) et le programme FT ( p 0,0001). Conclusion La rehabilitation rapide apres chirurgie colorectale reduit significativement la duree d’hospitalisation sans augmenter la morbidite. Nos resultats nous permettent de moduler le programme FT en fonction de l’âge et de la voie d’abord. Enfin, la satisfaction des patients FT est elevee.

Le sondage urinaire est-il nécessaire après chirurgie colique en Fast-Track avec une analgésie péridurale thoracique ? Une étude prospective (427)

Introduction Les patients se plaignent frequemment de symptomes urinaires causes par le sondage. Dans la chirurgie avec rehabilitation rapide (Fast-Track), le retrait de la sonde urinaire en fin de procedure chirurgicale pourrait etre associe a une faible morbidite, un faible risque de retention urinaire postoperatoire (RUPO), une mobilisation plus facile et un confort accru. Patients et Methodes Avec l’accord du Comite d’Ethique, les patients programmes pour une resection colique avec rehabilitation rapide, analgesie peridurale thoracique (T6-T8) et sans indication de sondage urinaire prolonge, ont ete inclus dans cette etude prospective observationnelle. La sonde urinaire a ete retiree a la fin de la chirurgie. Les criteres d’evaluation etaient l’incidence de RUPO, d’infections urinaires, le temps avant la premiere marche, la distance maximum parcourue (J1) et la satisfaction des patients.