Phénotypage métabolique par résonance magnétique nucléaire pour l’évaluation périopératoire et en réanimation

Metabolic phenotyping consists in the identification of subtle and coordinated metabolic variations associated with various pathophysiological stimuli. Different analytical methods, such as nuclear magnetic resonance, allow the simultaneous quantification of a large number of metabolites. Statistical analyses of these spectra thus lead to the discrimination between samples and the identification of a metabolic phenotype corresponding to the effect under study. This approach allows the extraction of candidate biomarkers and the recovery of perturbed metabolic networks, driving to the generation of biochemical hypotheses (pathophysiological mechanisms, diagnostic tests, therapeutic targets…). Metabolic phenotyping could be useful in anaesthesiology and intensive care medicine for the evaluation, monitoring or diagnosis of life-threatening situations, to optimise patient managements. This review introduces the physical and statistical fundamentals of NMR-based metabolic phenotyping, describes the work already achieved by this approach in anaesthesiology and intensive care medicine. Finally, potential areas of interest are discussed for the perioperative and intensive management of patients, from newborns to adults.     

Conception et évaluation de la qualité d’une information écrite sur le scanner et l’imagerie par résonance magnétique en neuropédiatrie

Introduction

We designed written information concerning two medical imaging techniques: the computed tomography scanner and the magnetic resonance imaging (MRI), and we evaluated the quality of the information in particular its readability.

Methods

Written information concerning scanner and MRI were elaborate starting from a reference frame based on a lexicon of the good practices. The written information sheets were initially reviewed by eight doctors, 45 nurses and by 26 couples of parents of hospitalized children, and finally by the communication and juridical services of our hospital. They were asked to improve the lexico-syntactic readability in order to increase the comprehension of the written information. Seventy-two couples of parents of hospitalized children who had not taken part of the protocol before evaluated the final version of the documents. The quality of the documents was evaluated using the scores of readability of Flesch and the Flesch-Kincaid, and a questionnaire of comprehension, managed before and after the delivery of written information.

Results

A total of 144 persons participated in the study. The number of right answers after reading written information increased by 38 % and by 35 % for the scanner and MRI information's respectively. Flesch and Flesch-Kincaid scores were not improved in the revised version of the written information compared to the first version.

Conclusion

Although readability scores for information sheets were low, our results suggest that they brought information, which contributed to a better understanding of these two medical imaging techniques by parents.     

Anesthésie locorégionale pour la chirurgie esthétique de la face et du cou

Plastic surgery is more and more developing. Facial blocks are adapted to surgical procedures performed in this setting. They are easy to perform and may prolong postoperative analgesia. Facial blocks may be used in ambulatory surgery as a single technique or combined with general anaesthesia or intravenous sedation. After a reminding of facial nerve anatomy, facial and cervical blocks are described with their indications. Guidelines for performance and monitoring are also indicated.     

Efficacité de l’infiltration cicatricielle subfasciale par la bupivacaïne dans la réduction de la douleur postopératoire des hernies inguinales

Introduction

The reduction of postoperative pain after surgery of inguinal hernia is an objective of lot of studies. The subfasciale infiltration of the wound may be an efficient technique.

Methods

This study was designed as a randomized, double blind, prospective study, comparing two treatment groups: a group infiltrated by bupivacaine (Gr B), and second one infiltrated by a placebo (Gr P). A part of demographic parameters and ASA class, the postoperative pain intensity at rest and at coughing, the morphine consumption and the secondary effects were compared. Patient's satisfaction and postoperative chronic pain at 3 and 6 months were also analyzed.

Results

Concerning demographic parameters, ASA class and secondary effects, we didn’t find any meaningful difference between the two groups. However, there was a significant reduction of postoperative pain in the bupivacaine group as well at rest as coughing. Gr P patients have more morphine consumption and they were unsatisfied and accused more chronic pain.

Discussion

Wound infiltration is still a simple and efficient technique in postoperative pain reduction. With this technique, hernia surgery may become ambulatory.     

Association nitroglycérine et remplissage vasculaire dans la chirurgie de l''aorte abdominale

Haemodynamic investigations were performed in nine patients during aortic surgery for Leriche's syndrome. Most of these patients had ischaemic heart disease without cardiac failure. Fluid loading was carried out before and during aortic clamping. It was controlled according to the optimal wedge pulmonary pressure determined the day before surgery. Only six of the nine patients receive nitroglycerin (NTG : 0.2 micrograms X kg-1 X min-1) throughout the operation. Before clamping, cardiac index was improved in patients treated with NTG. During clamping, the patients not treated with NTG showed a drop in cardiac index, an increase in peripheral resistance and in left cardiac work. After declamping, there were no haemodynamic differences between the two groups. Two patients not treated with NTG developed azotaemia postoperatively; one patient developed cardiac failure requiring a dopamine perfusion during surgery. In this series, the association of optimal volume loading with a peroperative perfusion of 0.2 micrograms X kg-1 X min-1 NTG gave a good haemodynamic stability.     

La préhabilitation. Préparer les patients à la chirurgie pour améliorer la récupération fonctionnelle et réduire la morbidité postopératoire

Objective

Prehabilitation consists in providing a repetitive physical exercise before surgery to improve the postoperative recovery course. This review aims to evaluate the feasibility and the expected benefits of prehabilitation on the postoperative recovery course and the reduction of the postoperative morbidity.

Data sources

Data research has focused on English-language articles in the Medline database, published from 1989 to 2013. Keywords, used separately or in combination, were: prehabilitation, functional capacity, postoperative morbidity, physical activity.

Study selection

Selected articles were original articles, clinical cases, review articles and meta-analysis.

Data extraction

Articles were analyzed for feasibility, benefits and limitations of preoperative physical preparation techniques.

Data synthesis

Poor preoperative functional status is associated with increased postoperative morbidity. Elderly are more prone to postoperative complications. The improvement of preoperative physical status of these patients is possible and may reduce morbidity and allow faster recovery after major surgery. In order to improve efficiency, the training program must provide endurance and muscle reinforcement exercises, whose intensity must be adapted to the patient's baseline physical abilities. An average of three sessions per week over a period of six to eight weeks before surgery seemed a good compromise between feasibility and effectiveness.

Conclusion

The effectiveness of prehabilitation has been demonstrated in cardiovascular surgery and probably in abdominal surgery. Prehabilitation must be integrated into the overall patient medical management, and must be associated with preoperative refeeding and postoperative rehabilitation protocols. By optimizing all stages of the surgical patient management, from diagnosis to recovery, prognosis of high-risk surgical patients could be improved.