J. Roigé

Observational study of nonogenarians undergoing emergency, non-trauma surgery

BACKGROUND Nonagenarian population is growing, and so is the number of them needing emergency surgery. Yet, their treatment is often based on the outcomes of younger patients: although old age is known to be a risk factor for surgery, its level is not clear. This is a prospective, observational study to describe the population. It is aimed at providing quantified scientific evidence of the current procedures and their outcomes. METHODS All non-traumatic nonagenarians who underwent surgery between July 2006 and September 2010 in our University Hospital were recruited and followed up over a month after discharge. A descriptive statistical analysis was performed. RESULTS Of the approximately 12 660 surgical emergencies, 102 were nonagenarians: 69.6% were women, who mostly had an ASA score III (62.7%). Perioperative morbidity and mortality rates of 61.6% [95% confidence interval (CI): 52.33-71.19%] and 35.3% (95% CI: 26.01-44.57%), respectively, were found statistically associated with preoperative neoplasms. The most frequent causes of surgery were acute limb arterial thrombosis (20), incarcerated hernia (17), and bowel occlusion (14). Confusion, renal failure, and abdominal problems accounted for the most frequent causes of morbidity. Among them, abdominal complications, cardiogenic pulmonary oedema, aspiration, stroke, and renal failure were associated with mortality. CONCLUSIONS The study gave scientific support and actual figures to many intuitive beliefs: morbidity and mortality are high and are associated with many preoperative comorbidities. All this, combined with an already reduced life expectancy, and a presumably low physiological reserve makes these patients particularly vulnerable to emergency surgery.

Oclusión traqueal fetoscópica (FETO) para el tratamiento de la hernia diafragmática congénita severa: resultados preliminares

OBJECTIVES: To evaluate survival and lung growth in fetuses with severe congenital diaphragmatic hernia (CDH) treated with fetoscopic tracheal occlusion (FETO) compared with control fetuses and to analyze possible complications of the anesthetic techniques used. PATIENTS AND METHODS: This prospective study was performed on fetuses with CDH. FETO was undertaken before the 29th week of gestation on fetuses with a lung-to-head ratio (LHR) less than 1. FETO was not performed on fetuses with an LHR between 1.0 and 1.5 or those with an LHR less than 1 where consent was not given. Lung growth was monitored by means of LHR. FETO was performed under fetal intramuscular anesthesia and maternal epidural anesthesia and sedation with remifentanil. RESULTS: Seventeen fetuses were included in the study. FETO was performed on 11 fetuses and was effective in 9. The median percentage difference between LHR at diagnosis and prior to FETO was 1.15% (P=.183); between diagnosis and before removing the balloon, the difference was 130.5% (P=.003); and between diagnosis and before delivery, 90.18% (P=.003). In the control group (n=6), the median percentage difference between LHR at diagnosis and before delivery was 49.25% (P=.028). No significant hemodynamic or respiratory changes occurred in either mother or fetus during fetoscopy. All the fetuses in the control group died; 45.5% of those in the FETO group survived. CONCLUSIONS: The use of FETO in cases of CDH appears to increase survival and lung growth. Fetal anesthesia in association with maternal epidural anesthesia and sedation makes it possible to place and remove the endotracheal balloon via fetoscopy with acceptable maternal comfort and without notable complications.

Conflicts between anaesthetists and surgeons: 15AP1-1

preanesthesia (the only -2 agonist locally available at the moment) was compared to placebo. Materials and Methods: Two equivalent groups of 40 patients (ASA I–III) were randomised to receive Diazepam in the evening before and oral Clonidine 150 g or placebo in the morning of the surgery. They have received equivalent ballanced general anesthesia for medium amplitude abdominal procedures. Intraand postoperative haemodynamic was assesed, as well as opiod consumption during surgery, opioid antagonisation at emergence. Anxiety, sedation, postoperatory respiratory depression and analgesia were quantified at 5 min postoperatory, at 1 h, then each 3 h until 24 h. Patients’ satisfaction (pain control, side effects) was assesed by a self-administred questionnaire in day 4. The statistic significance of the differences observed in the evolution of these parameters was tested by T Student test. Results and Discussions: Haemodynamic was better in the Clonidine group (variation greater than 20% for arterial pressure and heart rate at induction and during surgery for placebo group, p 0.05). This was even stronger for hypertensive patients. Opioid consumption reported to the duration of the intervention was comparable in the two groups Sedation and respiratory depression was slightly higher in the Clonidine group during the first 12 hours (p 0.05), Analgetic consumption was not statistically different in the two groups, as well as the pain control, Postoperative satisfaction (pain control, sedation, other side effects) was equivalent in the two groups. Conclusion(s): Clonidine premedication for moderate amplitude abdominal surgery ensures a better haemodynamic both intraand postoperatively, with minor side effects concearning sedation and respiratory depression. References: Bonnet F, Houhou A, Aveline C, ESA Refresher Courses 2000. Foëx P, Sear JW Continuing Education in Anaesthesia, Critical Care & Pain 2004 4(5): 139–143. 182 Education, research and presentation