Valérie Billard

Optimization of Hyperthermic Intraperitoneal Chemotherapy With Oxaliplatin Plus Irinotecan at 43°C After Compete Cytoreductive Surgery: Mortality and Morbidity in 106 Consecutive Patients

BackgroundPeritoneal carcinomatosis (PC), which has hitherto been regarded as a lethal entity, can now be cured with surgery (treating macroscopic tumor seeding) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) (treating residual microscopic disease). The purpose of this study was to analyze the morbidity and mortality of a particular approach associating optimal (R0–R1) cytoreduction, optimal HIPEC combining oxaliplatin and irinotecan, and an optimal homogeneous intraperitoneal temperature of 43°C.MethodsA total of 106 consecutive patients were included in this prospective phase 2 study. After complete resection of the PC, HIPEC was performed by the Coliseum technique with oxaliplatin (360 mg/m2) combined with irinotecan (360 mg/m2) in 2 L/m2 of 5% dextrose, over 30 minutes at a real intraperitoneal temperature of 43°C. During the hour preceding HIPEC, patients received 5-fluorouracil (400 mg/m2) and leucovorin (20 mg/m2) intravenously, resulting in tritherapy.ResultsPostoperative mortality and morbidity rates were 4% and 66%, respectively. The most frequent complications were digestive fistula (24%), lung infection (16%), and severe hematological toxicity (11%). Statistical correlation was evidenced between morbidity and the carcinomatosis score (P = .0008), the number of resected organs (P = .0001), the duration of surgery (P = .0001), and blood loss (P = .0001).ConclusionsThis new approach, optimized in three respects (complete cytoreduction, combination oxaliplatin with irinotecan, and high temperature) has resulted in a relatively high but acceptable incidence of adverse events considering the expected advantage for survival.

Muscle relaxation and increasing doses of propofol improve intubating conditions.

PurposeMuscle relaxants and anesthetics are usually associated during intubation. However, their relative role to facilitate the process is not dearly defined. This study was designed to determine, during intubation: i) the relative role of anesthetics and atracurium-induced neuromuscular block and; ii) the effect of different doses of propofol in the presence of complete muscle block.MethodsPatients were randomized to four groups and received fentanyl and a standardized anesthetic procedure. Patients from groups high (H;n = 45), medium (M;n = 48) and low(L;n = 47) received 2.5 mg· kg−1, 2.0 mg· kg−1, and 1.5 mg· kg−1 of propofol respectively, Atracurium (0.5 mg· kg−1) was then injected and tracheal intubation performed once complete block was achieved at the orbicularis oculi. Patients from group without atracurium (WA;n = 20) received propofol as in group H. Intubation was performed at the expected onset time of action of atracurium.ResulteUsing the same dose of propofol, the incidence of good or excellent intubating conditions was 35% without atracurium and 95% with atracurium (P < 0,0001), In patients receiving atracurium, clinically acceptable intubating conditions were more frequently achieved in groups receiving the highest propofol doses (group H or M vs group L;P < 0.03).ConclusionOur study confirms the interaction between anesthesia and muscle relaxation to produce adequate intubating conditions. In the conditions described, intubating conditions were more dependent on atracurium-induced neuromuscular blockade than on anesthetics, but both atracurium and propofol improved intubating conditions.RésuméObjectifAgents d’anesthésie et curares sont souvent associés pour l’intubation. Cependant, leurs rôles respectifs pendant l’intubation ne sont pas clairement définis. Cette étude a pour objectif de différencier pour l’intubation i) l’effet des agents d’anesthésie de ceux du bloc moteur induit par l’atracurium et ii) le rôle de différentes doses de propofol couplées à un bloc moteur complet induit par l’atracurium.MéthodeLes patients étaient randomisés en quatre groupes. Tous recevaient du fentanyl et une procédure d’anesthésie standardisée. Les patients des groupes high (H; n = 45), medium (M; n = 48), et low (L; n = 47) recevaient respectivement 2,5 mg· kg−1, 2,0 mg· kg−1 et 1,5 mg· kg−1 de propofol puis atracurium 0,5 mg· kg−1. Lintubation était réalisée et cotée après qu’un bloc complet avait été obtenu à l’orbiculaire de l’œil. Les patients du groupe n’ayant pas reçu l’atracurium (WA) recevaient le propofol comme dans le groupe H, et étaient intubés après un intervalle de temps correspondant à celui du délai d’action supposé de l’atracurium.RésultatsChez les patients recevant des doses d’anesthésie équivalentes, les conditions d’intubation étaient significativement meilleures chez ceux recevant l’atracurium (groupe H) par rapport aux patients WA (P < 0,0001). Pour les patients recevant de l’atracurium, les conditions d’intubation étaient significativement meilleures chez les patients du groupe H ou M par rapport aux patients du groupe L (P < 0,03).ConclusionLes conditions d’intubation dépendent plus du bloc neuromusculaire que des agents d’anesthésie lorsque l’on attend l’installation complète du bloc. Cependant, les conditions d’intubation dépendent aussi du rôle des agents d’anesthésie lors de l’intubation avec une curarisation complète.

Limits of laryngeal mask airway in patients after cervical or oral radiotherapy

PurposeTo test the efficacy of the LMA in patients with previous oral or cervical radiotherapy, without upper airway obstruction.MethodsIn nine patients after oral or cervical radiotherapy, efficiency of ventilation was assessed after induction of general anaesthesia and LMA insertion. Fibreoptic examination through the tube was performed to check the position of LMAResultsIn patients who had had oral radiotherapy, all five had limited mouth opening and in two, LMA insertion was difficult but permitted good ventilation. In the four patients who had had cervical radiotherapy, LMA insertion was easy but, in two, the lungs were difficult to ventilate and, in two, the lungs could not be ventilated and orotracheal intubation was required.ConclusionIn patients with limitation of mouth opening after oral radiotherapy, LMA may represent an alternative to tracheal intubation. In patient with cervical sclerosis after radiotherapy; the use of LMA should be avoided.RésuméObjectifTester l’efficacité du masque laryngé chez des patients ayant subi une radiothérapie orale ou cervicale, sans obstruction des voies aériennes supéneures.MéthodesChez neuf patients ayant subi de la radiothérapie, la qualité de la ventilation a été appréciée après induction de l’anesthésie générale. Une fibroscopie à travers le tube a été effectuée pour apprécier la position du masque laryngé.RésultatsChez les patients qui ont eu une radiothérapie orale, cinq avaient une limitation de l’ouverture de bouche. Chez deux d’entre eux, la pose du masque a été difficile mais a permis une bonne ventilation. Chez les quatre patients ayant eu une radiothérapie cervicale, la pose a été facile; la ventilation a été difficile chez deux d’entre eux et impossible chez les deux autres, nécessitant l’intubation trachéale.ConclusionChez les patients ayant une limitation de l’ouverture buccale après radiothérapie orale, le masque laryngé peut être une alternative à l’intubation. Chez les patients ayant une sclérose cervicale après radiothérapie de sclérose cervicale consécutive à la radiothérapie, il faut éviter d’utiliser le masque laryngé.

Surgical management of posterior pharyngeal wall carcinomas: Functional and oncologic results

The optimal primary treatment for posterior pharyngeal wall tumors remains controversial.

Major abdominal surgery for cancer: Does epidural analgesia have a long-term effect on recurrence-free and overall survival?

BACKGROUND Retrospective studies have suggested that regional analgesia combined with general anaesthesia could decrease cancer recurrence. The purpose of this study was to assess the influence of regional analgesia on recurrence-free (RFS) and overall survival in patients undergoing major intra-abdominal surgery for cancer. METHOD Patients previously included in a prospective randomized study comparing two postoperative techniques of analgesia were retrospectively studied. The EP group received general anaesthesia with bupivacaine thoracic epidural analgesia and the SC group received general anaesthesia with fentanyl followed by continuous subcutaneous morphine. RESULTS One hundred and thirty-two patients were analyzed (63 and 69 in SC and EP group, respectively) with a 17-year-median follow-up. After 5 years, RFS was 43% [95% CI: 32%-55%] in EP group and 24% [95% CI: 15%-36%] in SC group, but the difference did not reach statistical significance for RFS nor for overall survival (P=0.10 and 0.16 respectively). Using multivariable analysis over the whole follow-up period, the type of analgesia was not a statistically significant predictive factor for RFS (EP/SC, HR=1.3 [95% CI: 0.8-2.0%]). The anaesthesia effect changed moderately over the follow-up and HR for overall survival (EP/SC) reached statistical significance after 5, 6 and 8 years. CONCLUSION Despite a trend in favour of the epidural, this retrospective review of patients included in a previous randomized study failed to demonstrate a statistically significant association between the perioperative analgesia and RFS after abdominal surgery for cancer. The duration of follow-up may have an impact on the analgesia effect on survival.

Optimisation de l’administration des agents anesthésiques inhalés : débit de gaz frais ou fraction délivrée ?

INTRODUCTION During volatile closed-circuit anaesthesia, a chosen end-tidal fraction (Fet) could be achieved by setting either delivered fraction (Fd) or fresh gas flow (FGF). This study compared the efficacy of both strategies and the resulting drug consumption. PATIENTS AND METHODS Sixty patients (10 per group) were administered, after intravenous induction and intubation, desflurane, sevoflurane or isoflurane+50% N(2)O, to achieve a target Fet equal to one minimal alveolar concentration (MAC), according to one strategy: high FGF (HFGF) Fd fixed 20% above target Fet, FGF 10 l/min then 1l/min after achieving the target, FGF opened at 10 l/min at the end of surgery; low FGF (LFGF) FGF fixed at 1l/min, Fd at the maximal value on the vaporizer, then set at target Fet+20% after achieving Fet equal to one MAC, FGF maintained at 1l/min until extubation. RESULTS The target Fet was achieved in all patients in LFGF within 2.1+/-0.9 min followed by 15% (isoflurane) to 57% (sevoflurane) overdosage, but only in nine patients out of 30 after 10 min in HFGF. Delays were similar between desflurane and sevoflurane. Volatile consumption was decreased by 75% in LFGF. Fifty percent decrement and extubation times were shorter with HFGF, similarly for the three agents. CONCLUSION Massive overdosage of Fd is the fastest, reproducible and cheapest strategy to achieve (or to increase) a chosen Fet. High FGF is the fastest to decrease Fet during or at the end of anaesthesia. Combining Fd and FGF adjustments in order to maximize Fd/Fet gradients overwrites pharmacokinetic differences between desflurane and sevoflurane and reduces differences with isoflurane. Automatic adjustments based on volatile pharmacockinetics would be helpful to achieve a target Fet without overdosage.

Surveillance et impact budgétaire des pannes des appareils d'anesthésie

Resume Objectifs. – Evaluer le taux, la nature, les moyens de reparation utilises et le cout des pannes des machines d’anesthesie liees a leur vieillissement. Type d’etude. – Etude prospective de janvier 1996 a juillet 2000. Materiel et methodes. – La nature (mecanique ou electronique), la circonstance de decouverte (realisation de la checklist, reprise de maintenance et procedure de controle qualite), les moyens de reparation utilises et les couts de maintenance generes par les pannes d’appareils d’anesthesie sont releves et repertories dans une base de donnees sur un parc de 14 appareils d’anesthesie reparti sur 12 sites interventionnels. Resultats. – Sur 31 948 anesthesies realisees, 614 pannes ont ete declarees : 53 % etaient liees a une defaillance mecanique du ventilateur et a des problemes de capteurs ; 40 % ont ete detectees au cours de la checklist et 50 % resolues sur place. Globalement le taux annuel de pannes reste stable sur la periode etudiee et les couts de maintenance annuels s’elevent a environ 10 % de la valeur d’achat. Aucune intervention n’a ete annulee ou reportee suite a une panne d’appareil d’anesthesie. Conclusion. – L’evolution dans le temps du taux de pannes des machines d’anesthesie ne peut representer un critere de remplacement des machines si des procedures de controle qualite et de maintenance rigoureuses existent. 2003 Tous droits reserves. Editions scientifiques et medicales Elsevier SAS

Sufentanil en anesthésie balancée : Intérêt de prédire les concentrations pour optimiser les doses

During balanced anaesthesia sufentanil may be difficult to use, as the required doses change over time depending on the patient and the noxious stimuli. Patient adjustment may be improved by using pharmacokinetic simulations that predict the concentration achieved in the body. In the first case report, sufentanil was given manually as repeated boluses, then by infusion. As haemodynamic status remained unstable, a simulation of the sufentanil concentration time course was started during the case. It showed that instability had pharmacokinetic explanation and allowed to determine the adequate sufentanil concentrations (0.30-0.40 ng.mL-1 + N2O + isoflurane 0.8-1 vol% for abdominal surgery). However, adjusting the doses manually required numerous human actions. In the second case, sufentanil was given as a computer-controlled infusion. The adequate concentrations were determined (0.15-0.20 ng.mL-1 + N2O + isoflurane 0.4 vol% for peripheral surgery in an aged cardiac patient). They were maintained with a limited number of human actions and resulted in satisfactory haemodynamic stability.

Un indice bispectral étrangement élevé

We report a case of a falsely elevated-bispectral index (BIS) during a general anaesthesia combining remifentanil TCI, desflurane and nitrous oxide for an isolated-limb chemotherapy. During surgery, BIS increased and stabilized around 70, with neither residual neuromuscular blockade nor clinical sign of awareness. These high BIS values were attributed to high-electromyographic activity and electric artefacts, such as extracorporeal-circulation machine and tourniquet. At the end of the surgery, the BIS returned to expected values around 50. The patient did not complain of intraoperative recall. This case reminds us that the BIS has some limits as being sensitive to EMG or environment artefacts that should be eliminated before deepening anesthesia. To do so, a decision algorithm is proposed that may be used for all situations of surprising high BIS, taking into account the level of neuromuscular blockade, clinical response to orders and the presence of devices likely to induce electrical or mechanical artefacts.

Perioperative management of patients with coronary artery disease undergoing non-cardiac surgery: Summary from the French Society of Anaesthesia and Intensive Care Medicine 2017 convention

This review summarises the specific stakes of preoperative, intraoperative, and postoperative periods of patients with coronary artery disease undergoing non-cardiac surgery. All practitioners involved in the perioperative management of such high cardiac risk patients should be aware of the modern concepts expected to decrease major adverse cardiac events and improve short- and long-term outcomes. A multidisciplinary approach via a functional heart team including anaesthesiologists, cardiologists and surgeons must be encouraged. Rational and algorithm-guided management of those patients should be known and implemented from preoperative to postoperative period.