A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight

We conducted an observational prospective multicenter study to describe the practices of mechanical ventilation, to determine the incidence of use of large intra‐operative tidal volumes (≥ 10 ml.kg^?1 of ideal body weight) and to identify patient factors associated with this practice. Of the 2960 patients studied in 97 anaesthesia units from 49 hospitals, volume controlled mode was the most commonly used (85%). The mean (SD) tidal volume was 533 (82) ml; 7.7 (1.3) ml.kg^?1 (actual weight) and 8.8 (1.4) ml.kg^?1 (ideal body weight)). The lungs of 381 (18%) patients were ventilated with a tidal volume > 10 ml.kg^?1 ideal body weight. Being female (OR 5.58 (95% CI 4.20–7.43)) and by logistic regression, underweight (OR 0.06 (95% CI 0.01–0.45)), overweight (OR 1.98 (95% CI 1.49–2.65)), obese (OR 5.02 (95% CI 3.51–7.16)), severely obese (OR 10.12 (95% CI 5.79–17.68)) and morbidly obese (OR 14.49 (95% CI 6.99–30.03)) were the significant (p ≤ 0.005) independent factors for the use of large tidal volumes during anaesthesia.     

Œsophagectomie carcinologique : 16 ans d’évolution des pratiques anesthésiques ventilatoires,hémodynamiques et analgésiques

Objective

To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery.

Patients and methods

We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994–2009). Statistical analysis was done on 4 chronologic quartiles of same sample size.

Results

Two hundred and seven consecutive patients were included during the 4 periods 1994–1997 (n = 52), 1997–1999 (n = 52), 1999–2003 (n = 52) and 2004–2009 (n = 51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6–10.6] vs 7.6[7.0–8.3] mL/kg of ideal body weight (IBW), p < 0.01), increased use of Positive End Expiratory Pressure (0 vs 83 %, p < 0.001) and increased use of post-operative non-invasive ventilation (0 vs 51 %, p < 0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0–24.6] vs 12.6 [9.7–16.2] mL/h/kg of IBW, p < 0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57 %, p < 0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn’t change.

Conclusions

During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed.     

Risque barotraumatique avec des valves de non-réinhalation de Waters : étude comparative sur banc d’essai

Objective

Manual ventilation is delivered in the operating room or the intensive care unit to intubated or non-intubated patients, using non-rebreathing systems such as the Waters valve. New generation Waters valves are progressively replacing the historic Waters valve. The aim of this study was to evaluate maximal pressure delivered by these 2 valves.

Type of study

Bench test.

Material and method

Thirty-two different conditions were tested, according to 2 oxygen flow rates (10 and 20 L/min), without (static condition) or with manual insufflations (dynamic condition) and 4 valve expiratory opening pressures. The primary endpoint was maximal pressure measured at the exit of the valve, connected to a model lung and a bench test.

Results

Measured pressures were different for most evaluated conditions. Increasing oxygen flow from 10 to 20 L/min increased maximal pressure for both valves. Increasing valve expiratory opening pressure induced a significant increase in maximal pressure for the new generation valve (from 4 to 61 cmH₂O in static conditions and from 18 to 68 cmH₂O in dynamic conditions). For the historic valve, maximal pressure increased significantly but remained below 15 cmH₂O in both static and dynamic conditions.

Conclusion

Use of new generation Waters valves should be different from historic Waters valves. Indeed, barotrauma could be caused by badly adapted valve expiratory opening pressure settings.     

Grippe A (H1N1) et SDRA : caractéristiques des patients admis en réanimation et prise en charge. Revue de la littérature

Novel influenza A (H1N1) at the origin of the 2009 pandemic flu developed mainly in subjects of less than 65 years contrary to the seasonal influenza, which usually developed in elderly patients of more than 65 years. Elderly subjects are partly protected by old meetings with close stocks. Influenza A(H1N1) can arise in serious forms within 60 to 80% of cases a fulminant acute respiratory distress syndrome (ARDS) “malignant and fulminant influenza” in subjects without any comorbidity, which makes the gravity and the fear of this influenza. The fact that this influenza A (H1N1) can develop in healthy young patients and evolve in few hours to a severe ARDS with a refractory hypoxemia gave to the foreground the possible interest of the recourse to extracorporeal oxygenation (ECMO) in some selected severe ARDS (5–10%). The first publications of patients admitted in intensive care unit (ICU) for severe influenza A (H1N1) often associated to an ARDS reported a mortality rate from 15 to 40%. This mortality variability may be explained in part by different studied populations, ARDS characteristics and human and material resources in the ICUs between the countries. Indeed, the highest mortality rates (30–40%) have been reported by in Mexico which were affected the first by pandemic flu and which were not prepared. A bacterial pneumonia was associated to H1N1 influenza in approximately 30% of the cases as at admission in ICU or following the days of the admission justifying an early antibiotherapy associated to the antiviral treatment by oseltamivir (Tamiflu^®). Obesity, pregnancy and respiratory diseases (asthma, COPD) seem to be associated to the development of a severe viral pneumonia due to influenza A (H1N1) often with ARDS. Older age, high APACHE II and SOFA scores and a delay of initiation of the antiviral treatment by oseltamivir are associated to higher morbidity and mortality. Other analyses of the results obtained from the first published papers included more patients and future studies would permitted to better define the role of therapeutics such as steroids and ECMO.     

Laparoscopic Sleeve Gastrectomy for Late Adolescent Population

Background

Morbid obesity prevalence is rapidly increasing among adolescents worldwide. Evidence is mounting that bariatric surgery is the only reliable method for substantial and sustainable weight loss; however, the debate continues with regard to the optimal surgical procedure for adolescents and to the age limit when bariatric surgery should be proposed.

Methods

A retrospective multicenter review included all late adolescent patients (<20 years old) who underwent sleeve gastrectomy from 2005 to 2012 in three French bariatric centers: Montpellier University Hospital, Casamance Private Hospital, and Noumea Regional Hospital. Collected data included age, sex, body mass index (BMI), intraoperative complications, length of hospital stay, operative morbidity, the need for reoperation, and percentage of excess weight loss (% EWL) at 6 months, 1 year, and 2 years postoperatively.

Results

A total of 61 adolescent patients have undergone sleeve gastrectomy. Of these, 42 were women and 19 were men. The mean preoperative weight was 132.8 kg (range 90–217 kg) with a BMI of 46.7 (range 35.5–68.7). Seventeen patients (27.9 %) were superobese (BMI?>?50), and seven patients (11.5 %) were supersuperobese (BMI?>?60). All the procedures were performed by laparoscopy with no intraoperative complications. The mean hospital stay was 4.6 days. Four major complications were recorded: one staple line leak, two hematomas, and one case of pneumonia. No mortality was recorded. The % EWL at 6 months, 1 year, and 2 years postoperatively was 48.1 % (±17.9 %), 66.7 % (±19.5 %), and 78.4 % (±16.8 %), respectively, for a follow-up of 93.4, 81.9, and 52.4 %, respectively. There were 18 patients (29.5 %) with identified comorbid conditions: 10 cases of sleep apnea, 7 cases of hypertension, and 1 case of type 2 diabetes, with a resolution rate of 77.8 %.

Conclusions

Laparoscopic sleeve gastrectomy may be advantageous for this age group, since it involves neither foreign body placement nor lifelong malabsorption. Laparoscopic sleeve gastrectomy represents an attractive bariatric procedure for adolescent patients, more efficient than gastric banding and with less morbidity compared to gastric bypass.     

Sédation-analgésie en réanimation : arrêt quotidien par les médecins ou gestion continue par les infirmières

During the past decade, practice in sedation and analgesia has progressed with the use of new drugs and administration strategies including algorithm-based protocols of drug administration by nurses and daily interruption of sedatives and analgesics. Implementation of each of these strategies has been demonstrated to reduce duration of mechanical ventilation and length of stay in the intensive care unit as well as 6-month mortality rate in one study. In contrast to the daily interruption of sedation which seems easy to implement at the individual level of the primary care physician, implementation of a sedation protocol requires a large education and training of the whole nurse team. This training aims at managing not only the clinical tools used to standardize the subjective assessment of sedation and pain levels but also the sedation protocols of variable complexity. Published trials comparing sedation protocol implementation versus daily interruption of sedation are limited, making difficult any definitive conclusion regarding the feasibility and effectiveness of each of these strategies. Both strategies should not be opposed but considered as complementary. Protocols should be used to avoid overdose in sedation-analgesia and criteria allowing for the daily interruption of sedation-analgesia checked to avoid futile administration. Clinical studies are mandatory to determine which sedation interruption criteria are the most feasible, effective and safe. The impact of pain and neuropsychological disorders after sedation interruption should be also clearly evaluated. Education of nursing staff should be one of the top priority in regards to sedation management and interruption.     

Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis

Purpose

Single studies of video laryngoscopy (VL) use for airway management in intensive care unit (ICU) patients have produced controversial findings. The aim of this study was to critically review the literature to investigate whether VL reduces difficult orotracheal intubation (OTI) rate, first-attempt success, and complications related to intubation in ICU patients, compared to standard therapy, defined as direct laryngoscopy (DL).

Methods

We performed a systematic review and meta-analysis of randomized controlled trials, as well as prospective and retrospective observational studies, by searching PubMed, EMBASE, and bibliographies of articles retrieved. We screened for relevant studies that enrolled adults in whom the trachea was intubated in the ICU and compared VL to DL. We included studies reporting at least one clinical outcome of interest to perform a meta-analysis. We generated pooled odd ratios (OR) across studies. The primary outcome measure was difficult OTI. The secondary outcomes were first-attempt success, Cormack 3/4 grades, and complications related to intubation (severe hypoxemia, severe cardiovascular collapse, airway injury, esophageal intubation).

Results

Nine trials with a total of 2,133 participants (1,067 in DL and 1,066 in VL) were included in the current analysis. Compared to DL, VL reduced the risk of difficult OTI [OR 0.29 (95 % confidence interval (CI) 0.20–0.44, p < 0.001)], Cormack 3/4 grades [OR 0.26 (95 % CI 0.17–0.41, p < 0.001)], and esophageal intubation [0.14 (95 % CI 0.02–0.81, p = 0.03)] and increased the first-attempt success [OR 2.07 (95 % CI 1.35–3.16, p < 0.001)]. No statistically significant difference was found for severe hypoxemia, severe cardiovascular collapse or airway injury.

Conclusions

These results suggest that VL could be useful in airway management of ICU patients.