Service dAnesthesie

Nantes, France

Service dAnesthesie

Nantes, France

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Alfonsi P.,Service anesthesie reanimation | Slim K.,Estaing University Hospital Center | Chauvin M.,Service anesthesie reanimation | Mariani P.,University Pierre and Marie Curie | And 2 more authors.
Journal of visceral surgery | Year: 2014

Enhanced recovery after surgery provides patients with optimal means to counteract or minimize the deleterious effects of surgery. This concept can be adapted to suit a specific surgical procedure (i.e., colorectal surgery) and comes in the form of a program or a clinical pathway covering the pre-, intra- and postoperative periods. The purpose of these Expert Panel Guidelines was firstly to assess the impact of each parameter typically included in the fast-track programs on six foreseeable consequences of colorectal surgery: surgical stress, postoperative ileus, fluid and electrolyte imbalances, decreased postoperative mobility, sleep disorders and postoperative complications; secondly, to validate the value of each parameter in terms of efficacy criteria for success of rapid rehabilitation programs. Two primary endpoints were selected to evaluate the impact of each parameter: the duration of hospital stay and rate of postoperative complications. For some of the parameters, the lack of information in the literature forced the experts to assess the parameter using different criteria (i.e., the duration of postoperative ileus or quality of analgesia); improvement in endpoints favored the implementation of a rapid rehabilitation program. After analysis of the literature, 19 parameters were identified as potentially impacting at least one of the foreseeable consequences of colorectal surgery. GRADE(®) methodology was applied to determine a level of evidence and the strength of recommendation regarding each parameter. After synthesis of the work of experts on the 19 parameters using GRADE(®) methodology, the organizing committee reached 35 formal recommendations. The recommendations were submitted and amended by a group of reviewers. After three rounds of Delphi quotes, strong agreement was obtained for 28 recommendations (80%) and weak agreement for seven recommendations. Consensus was reached among anesthesiologists and surgeons on a number of tactics that are insufficiently applied in current rehabilitation programs in colorectal surgery such as: pre-operative intake of carbohydrates; optimization of intra-operative volume control; resumption of oral feeding within 24 hours; gum chewing after surgery; getting the patient out of bed and walking on D1. The panel also clarified the value and place of such approaches as: patient information; pre-operative immunonutrition; laparoscopic surgery; antibiotic prophylaxis; prevention of hypothermia; systematic medication to prevent nausea and vomiting; morphine-sparing analgesia techniques; indications and techniques for bladder catheterization. The panel also confirmed the futility of other methods such as: bowel preparation for colon surgery; maintaining a nasogastric tube; surgical drainage for colorectal surgery. Copyright © 2013 Elsevier Masson SAS. All rights reserved.


Gicquel-Schlemmer B.,Service dorthopedie traumatologie | Beller J.-P.,Service danesthesie | Mchalwat A.,Service danesthesie | Gicquel P.,Service de chirurgie pediatrique
Orthopaedics and Traumatology: Surgery and Research | Year: 2015

The authors report a case of a shoulder arthroscopy in which epinephrine saline irrigation was held responsible for acute hypertension followed by fatal Takotsubo cardiomyopathy. © 2015 Elsevier Masson SAS.


After knee and hip surgery, lower limb blocks impair deambulation due to a decrease in quadriceps muscle strength (femoral nerve block) or gluteal, hamstring and leg muscles strength (sciatic nerve block). The risk of fall is close to 1% after hip and knee surgery. The role of continuous femoral block is still debated. The risk of fall must be prevented by a careful evaluation of walking and muscle strength and by a material support combined with the help of health care providers. © 2014 Elsevier Masson SAS.


Mion G.,Groupe hospitalier Cochin Broca Hotel Dieu | Villevieille T.,Service danesthesie
CNS Neuroscience and Therapeutics | Year: 2013

For more than 50 years, ketamine has proven to be a safe anesthetic drug with potent analgesic properties. The active enantiomer is S(+)-ketamine. Ketamine is mostly metabolized in norketamine, an active metabolite. During "dissociative anesthesia", sensory inputs may reach cortical receiving areas, but fail to be perceived in some association areas. Ketamine also enhances the descending inhibiting serotoninergic pathway and exerts antidepressive effects. Analgesic effects persist for plasma concentrations ten times lower than hypnotic concentrations. Activation of the (N-Methyl-D-Aspartate [NMDA]) receptor plays a fundamental role in long-term potentiation but also in hyperalgesia and opioid-induced hyperalgesia. The antagonism of NMDA receptor is responsible for ketamine's more specific properties. Ketamine decreases the "wind up" phenomenon, and the antagonism is more important if the NMDA channel has been previously opened by the glutamate binding ("use dependence"). Experimentally, ketamine may promote neuronal apoptotic lesions but, in usual clinical practice, it does not induce neurotoxicity. The consequences of high doses, repeatedly administered, are not known. Cognitive disturbances are frequent in chronic users of ketamine, as well as frontal white matter abnormalities. Animal studies suggest that neurodegeneration is a potential long-term risk of anesthetics in neonatal and young pediatric patients. © 2013 John Wiley & Sons Ltd.


Boutonnet M.,Service dAnesthesie | Faitot V.,Service dAnesthesie | Katz A.,Service dAnesthesie | Salomon L.,Assistance Publique Hopitaux de Paris | Keita H.,Service dAnesthesie
British Journal of Anaesthesia | Year: 2010

BackgroundAn increase in Mallampati class is associated with difficult laryngoscopy in obstetrics. The goal of our study was to determine the changes in Mallampati class before, during, and after labour, and to identify predictive factors of the changes.MethodsMallampati class was evaluated at four time intervals in 87 pregnant patients: during the 8th month of pregnancy (T 1), placement of epidural catheter (T2), 20 min after delivery (T3), and 48 h after delivery (T4). Factors such as gestational weight gain, duration of first and second stages of labour, and i.v. fluids administered during labour were evaluated for their predictive value. Mallampati classes 3 and 4 were compared for each time interval. Logistic regression was used to test the association between each factor and Mallampati class evolution.ResultsMallampati class did not change for 37% of patients. The proportion of patients falling into Mallampati classes 3 and 4 at the various times of assessment were: T1, 10.3%; T2, 36.8%; T 3, 51.7%; and T4, 20.7%. The differences in percentages were all significant (P<0.01). None of the evaluated factors was predictive.ConclusionsThe incidence of Mallampati classes 3 and 4 increases during labour compared with the pre-labour period, and these changes are not fully reversed by 48 h after delivery. This work confirms the absolute necessity of examining the airway before anaesthetic management in obstetric patients.


Liu N.,Service DAnesthesie | Le Guen M.,Service DAnesthesie | Benabbes-Lambert F.,Service DAnesthesie | Chazot T.,Service DAnesthesie | And 3 more authors.
Anesthesiology | Year: 2012

BACKGROUND:: This randomized controlled trial describes automated coadministration of propofol and remifentanil, guided by M-Entropy analysis of the electroencephalogram. The authors tested the hypothesis that a novel dual-loop controller with an M-Entropy monitor increases time spent within predetermined target entropy rangE.S. METHODS:: Patients scheduled for elective surgery were randomly assigned in this single-blind study using a computer-generated list, to either dual-loop control using a proportional-integral-derivative controller or skilled manual control of propofol and remifentanil using target-controlled-infusion systems. In each group, propofol and remifentanil administration was titrated to a state entropy target of 50 and was subsequently targeted to values between 40 and 60. The primary outcome was the global score, which included the percentage of state entropy or response entropy in the range 40-60, the median absolute performance error and wobble. Data are presented as medians [interquartile range]. RESULTS:: Thirty patients assigned to the dual-loop group and 31 assigned to the manual group completed the study. The dual-loop controller was able to provide induction and maintenance for all patients. The Global Score of State Entropy was better maintained with dual-loop than manual control (25 [19-53] vs. 44 [25-110], P = 0.043), and state entropy was more frequently maintained in the range of 40-60 (80 [60-85] vs. 60 [35-82]%, P = 0.046). Propofol (4.1 [2.9-4.9] vs. 4.5 [3.4-6.3] mg • kg • h) and remifentanil (0.18 [0.13-0.24] vs. 0.19 [0.15-0.26] μg • kg • min) consumptions and the incidence of somatic side effects were similar. CONCLUSION:: Intraoperative automated control of hypnosis and analgesia guided by M-Entropy is clinically feasible and more precise than skilled manual control. Copyright © 2012, the American Society of Anesthesiologists, Inc. Lippincott.


Colchen A.,Unite dendoscopie | Fischler M.,Service danesthesie
Revue de Pneumologie Clinique | Year: 2011

An emergency interventional endoscopic procedure is often the only way to overcome an asphyxic or pre-asphyxic situation. From November 1978 to June 2010 we performed 9950 interventional endoscopies among which 20% were performed in an emergency context. To obtain a homogeneous study group, we reviewed the last four years. 344 interventional emergency endoscopies were done for the following indications: cancers (n=240, 70%), iatrogenic stenosis (n=63, 18%), foreign bodies (n=29, 8.5%), hemoptysis (12, 3.5%). The same technique was used in all cases: operating room, general anesthesia, rigid bronchoscope, laser, cryotherapy. Outcome was favorable in 85% of cancers and 100% in all other indications. Apart from clear-cut cases, it remains difficult to define the true emergency. Whatever the definition retained, a well-trained anesthetic and endoscopic team is crucial for proper intervention in these potentially life-threatening situations. © 2011 Elsevier Masson SAS.


Liu N.,Service dAnesthesie | Chazot T.,Service dAnesthesie | Hamada S.,Service dAnesthesie | Landais A.,Service dAnesthesie | And 7 more authors.
Anesthesia and Analgesia | Year: 2011

Background: We have developed a proportional-integral-derivative controller allowing the closed-loop coadministration of propofol and remifentanil, guided by a Bispectral Index (BIS) monitor, during induction and maintenance of general anesthesia. The controller was compared with manual target-controlled infusion. Methods: In a multicenter study, 196 surgical patients were randomly assigned to dual closed-loop or manual administration of propofol and remifentanil. Comparison between groups was evaluated by calculating a global score that characterized the overall performance of the controller including the percentage of adequate anesthesia, defined as BIS between 40 and 60, the median absolute performance error, and wobble. Secondary outcomes included occurrence of burst suppression ratio, time to tracheal extubation, and drug consumption. Results: Eighty-three patients assigned to dual-loop control and 84 patients assigned to manual control completed the study. The global score and the percentage of time with BIS between 40 and 60 were better in the dual-loop group (26 ± 11 vs 43 ± 40, P < 0.0001; 82% ± 12% vs 71% ± 19%, P < 0.0001). Overshoot (BIS <40), undershoot (BIS >60), and burst suppression ratio were all significantly less common in the dual-loop group. Modifications to the propofol and remifentanil infusions were more frequent, and adjustments smaller in the dual-loop group. Remifentanil consumption was greater (0.22 ± 0.07 vs 0.16 ± 0.07 μg • kg • min; P < 0.0001) and the speed to tracheal extubation was shorter (10 ± 4 vs 11 ± 5 minutes; P = 0.02) in the dual-loop group. Conclusion: The controller allows the automated delivery of propofol and remifentanil and maintains BIS values in predetermined boundaries during general anesthesia better than manual administration. Copyright © 2011 International Anesthesia Research Society.


Fletcher D.,Service dAnesthesie | Fletcher D.,French Institute of Health and Medical Research | Fletcher D.,University of Versailles | Martinez V.,Service dAnesthesie | And 2 more authors.
British Journal of Anaesthesia | Year: 2014

Background Opioids can increase sensitivity to noxious stimuli and cause opioid-induced hyperalgesia. We performed a systematic review to evaluate the clinical consequences of intra-operative doses of opioid. Methods We identified randomized controlled trials which compared intra-operative opioid to lower doses or placebo in adult patients undergoing surgery from MEDLINE, EMBASE, LILAC, Cochrane, and hand searches of trial registries. We pooled data of postoperative pain intensity, morphine consumption, incidence of opioid-related side-effects, primary and secondary hyperalgesia. For dichotomous outcomes relative risks [95% conïdence intervals (CIs)] and for continuous outcomes mean differences (MDs) or standardized mean difference (SMD; 95% CI) were calculated. Results Twenty-seven studies involving 1494 patients were included in the analysis. Patients treated with high intra-operative doses of opioid reported higher postoperative pain intensity than the reference groups (MD: 9.4 cm; 95% CI: 4.4, 14.5) at 1 h, (MD: 7.1 cm; 95% CI: 2.8, 11.3) at 4 h, and (MD: 3 cm; 95% CI: 0.4, 5.6) at 24 h on a 100 cm visual analogue scale. They also showed higher postoperative morphine use after 24 h (SMD: 0.7; 95% CI: 0.37, 1.02). There was no difference in the incidences of nausea, vomiting, and drowsiness. These results were mainly associated with the use of remifentanil. The impact of other opioids is less clear because of limited data. Discussion This review suggests that high intra-operative doses of remifentanil are associated with small but significant increases in acute pain after surgery. © 2014 The Author.


Bouzinac A.,Service dAnesthesie
Praticien en Anesthesie Reanimation | Year: 2016

Ultrasonography allows developing new techniques of regional anesthesia in the setting of postoperative pain control after breast surgery: the PEC 1 and 2 blocks, and the serratus plane block. The PEC block 1 provides pectoralis major muscle relaxation that is useful for reconstructive breast surgery or complete mastectomy. The PEC block 2 and the serratus plane block concerning the lateral endings of the intercostal nerves could be promoted asalternative to the paravertebral block. These blocks can be performed under general anesthesiaor sedation. They can be combined depending on the surgical area and the extension of sensoryblock required. © 2015 Elsevier Masson SAS.

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