Publications by authors named "Charles Tacquard"

21 Publications

  • Page 1 of 1

Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms.

Eur J Anaesthesiol 2021 May 10. Epub 2021 May 10.

From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AGC, EK, PM, DL), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France (AGC), Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA (AGC), Pulmonology Department, Bichat Hospital, AP-HP, Paris University (CN), INSERM UMR 1152, Paris University, DHU FIRE, Paris (CN, PM), Anaesthesiology and Critical Care Medicine Department, Maison Blanche Hospital, Centre Hospitalier Universitaire de Reims, Reims (JM-M), Anaesthesiology and Critical Care Medicine Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (CT, PM-M), Paris University (PM, DL), EA 3072, Institut de Physiologie, FMTS, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg (PM-M) and INSERM1148, Paris, France (DL).

Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.
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http://dx.doi.org/10.1097/EJA.0000000000001536DOI Listing
May 2021

Follow-up of COVID-19 patients: LA is transient but other aPLs are persistent.

Autoimmun Rev 2021 Jun 16;20(6):102822. Epub 2021 Apr 16.

Service d'Immunologie Clinique-Médecine Interne, Centre National de Référence des Maladies Auto-immunes et Systémiques Rares Est/Sud-Ouest RESO, Hôpitaux Universitaires de Strasbourg, France. Electronic address:

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http://dx.doi.org/10.1016/j.autrev.2021.102822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050395PMC
June 2021

Mast Cell Activation During Suspected Perioperative Hypersensitivity: A Need for Paired Samples Analysis.

J Allergy Clin Immunol Pract 2021 Apr 20. Epub 2021 Apr 20.

Faculty of Medicine and Health Sciences, Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, University of Antwerp, Antwerp, Belgium; Department of Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; AZ Jan Palfijn Gent, Department of Immunology and Allergology, Ghent, Belgium.

Background: Perioperative hypersensitivity (POH) reactions constitute a significant clinical and diagnostic challenge. A transient increase in serum tryptase during POH reflects mast cell activation (MCA) and helps to recognize an underlying hypersensitivity mechanism.

Objective: To determine the diagnostic performance of different tryptase decision thresholds based on single and paired measurements to document MCA in suspected POH.

Methods: Acute serum tryptase (aST) and baseline serum tryptase (bST) samples were obtained from patients referred to our outpatients clinic because of clinical POH. Tryptase samples from controls were obtained before induction (Tt) and 1.5 hours after induction (Tt) in uneventful anesthesia. Different cutoff points for tryptase increase over bST and the percentage increase in tryptase (%T) were calculated and compared with existing thresholds: aST > [1.2 × (bST) + 2] (consensus formula), aST higher than 11.4 ng/mL, and aST higher than 14 ng/mL.

Results: Patients with POH had higher bST and aST levels compared with controls (respectively 5.15 vs 2.28 ng/mL for bST and 20.30 vs 1.92 ng/mL for aST). The consensus formula and a tryptase increase over bST of greater than or equal to 3.2 ng/mL held the highest accuracies to document MCA in POH (respectively 81% and 82%). A bST of higher than 8 ng/mL was present in 4% of controls, 5% of patients with grade 1 POH, 24% of patients with grade 2 POH, 15% of patients with grade 3 POH, and 17% of patients with grade 4 POH.

Conclusions: Our data endorse the consensus formula for detection of MCA in POH. Furthermore, it shows that a bST of higher than 8 ng/mL was associated with occurrence of anaphylaxis.
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http://dx.doi.org/10.1016/j.jaip.2021.03.050DOI Listing
April 2021

Anticoagulation in COVID-19: not strong for too long?

Anaesth Crit Care Pain Med 2021 04 30;40(2):100857. Epub 2021 Mar 30.

Department of Anaesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France.

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http://dx.doi.org/10.1016/j.accpm.2021.100857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8008784PMC
April 2021

Use and Interpretation of Acute and Baseline Tryptase in Perioperative Hypersensitivity and Anaphylaxis.

J Allergy Clin Immunol Pract 2021 Mar 18. Epub 2021 Mar 18.

Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass. Electronic address:

Paired acute and baseline serum or plasma tryptase sampling and determination have recently been included as a mechanistic approach in the diagnostic and management guidelines of perioperative immediate hypersensitivity and anaphylaxis. The timing of this paired sampling is clearly defined in international consensus statements, with the optimal window for acute tryptase sampling between 30 minutes and 2 hours after the initiation of symptoms, whereas baseline tryptase should be measured in a sample collected before the event (preop) or at least 24 hours after all signs and symptoms have resolved. A transient elevation of the acute tryptase level greater than [2 + (1.2 × baseline tryptase level)] supports the involvement and activation of mast cells. Here, we provide the clinical, pathophysiological, and technical rationale for the procedure and interpretation of paired acute and baseline tryptase. Clinical examples, up-to-date knowledge of hereditary α-tryptasemia as a frequent cause of baseline tryptase of 7 μg/L and higher, mastocytosis, other clonal myeloid disorders, cardiovascular or renal failure, and technical improvements resulting in continued lowering of the 95th percentile value are discussed. Clues for improved management of perioperative immediate hypersensitivity and anaphylaxis include (1) sustained dissemination and implementation of updated guidelines; (2) preoperative sample storage for deferred analysis; (3) referral for thorough allergy investigation, screening for mast cell-related disorders, and recommendations for future anesthetic procedures; and (4) sustained collaboration between anesthesiologists, immunologists, and allergists.
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http://dx.doi.org/10.1016/j.jaip.2021.03.011DOI Listing
March 2021

Hemodynamic Management During Kidney Transplantation: A French Survey.

Transplant Proc 2021 Feb 6. Epub 2021 Feb 6.

Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France.

Background: Hypovolemia or excess fluid load during kidney transplantation may have detrimental effects on the recipient and graft. The aim of our survey was to examine hemodynamic monitoring during kidney transplantation (KT) in French KT centers.

Basic Procedures: The online survey covered the organization of anesthesia, the type of hemodynamic monitoring available in each center, the frequency of use of each hemodynamic parameter, and the hemodynamic algorithm used to manage fluid administration.

Main Findings: Twenty-four centers answered the survey (70% of all the 34 French KT centers) and reported performing 2029 KTs in 2016. Anesthesia for KT was performed either by a general team (n = 12, 48%) or less often, by a specific team during open hours (n = 7, 28%), a specific 24-hour/24-hour team (n = 5, 20%), or an emergency team (n = 1, 4%). The centers reported that up to 8 different hemodynamic monitoring techniques were available for KT. Central venous pressure (CVP) is the most frequently used hemodynamic parameter (1278 KT, 63%). Among the 17 centers using CVP monitoring, 9 had no specific algorithm and the other 8 centers used a different algorithm to manage fluids with CVP. The total fluids administered during KT varied from 1000 mL to 3500 mL.

Conclusions: CVP was still the main hemodynamic parameter used in France during KT in 2016. Our results suggest that a large randomized controlled trial should be performed to specifically address the question of hemodynamic management during KT.
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http://dx.doi.org/10.1016/j.transproceed.2021.01.008DOI Listing
February 2021

Impact of High-Dose Prophylactic Anticoagulation in Critically Ill Patients With Coronavirus Disease 2019 Pneumonia.

Chest 2021 Jan 16. Epub 2021 Jan 16.

Department of Anesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France.

Background: Because of the high risk of thrombotic complications (TCs) during severe acute respiratory syndrome coronavirus 2 infection, several scientific societies have proposed to increase the dose of preventive anticoagulation, although arguments in favor of this strategy are inconsistent.

Research Question: What is the incidence of TC in critically ill patients with coronavirus disease 2019 (COVID-19) and what is the relationship between the dose of anticoagulant therapy and the incidence of TC?

Study Design And Methods: All consecutive patients referred to eight French ICUs for COVID-19 were included in this observational study. Clinical and laboratory data were collected from ICU admission to day 14, including anticoagulation status and thrombotic and hemorrhagic events. The effect of high-dose prophylactic anticoagulation (either at intermediate or equivalent to therapeutic dose), defined using a standardized protocol of classification, was assessed using a time-varying exposure model using inverse probability of treatment weight.

Results: Of 538 patients included, 104 patients experienced a total of 122 TCs with an incidence of 22.7% (95% CI, 19.2%-26.3%). Pulmonary embolism accounted for 52% of the recorded TCs. High-dose prophylactic anticoagulation was associated with a significant reduced risk of TC (hazard ratio, 0.81; 95% CI, 0.66-0.99]) without increasing the risk of bleeding (HR, 1.11; 95% CI, 0.70-1.75).

Interpretation: High-dose prophylactic anticoagulation is associated with a reduction in thrombotic complications in critically ill COVID-19 patients without an increased risk of hemorrhage. Randomized controlled trials comparing prophylaxis with higher doses of anticoagulants are needed to confirm these results.

Trial Registry: ClinicalTrials.gov; No.: NCT04405869; URL: www.clinicaltrials.gov.
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http://dx.doi.org/10.1016/j.chest.2021.01.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7832130PMC
January 2021

Epidemiology and outcome of patients admitted to intensive care after anaphylaxis in France: a retrospective multicentre study.

Br J Anaesth 2020 12 12;125(6):1025-1033. Epub 2020 Sep 12.

Service d'Anesthésie-Réanimation Chirurgicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.

Background: Few data are available on patients who have experienced anaphylaxis and were admitted to ICUs. The purpose of this observational study was to describe the epidemiology and management of these patients.

Methods: This was a multicentre retrospective study carried out in 23 French ICUs between 2012 and 2017. All patients who suffered anaphylaxis and were transferred to an ICU were included. Data were collected using an electronic database after approval by an ethics committee.

Results: A total of 339 patients were included, and 17 (5%) died secondary to anaphylaxis. The main triggers were drugs (77%), contrast media (11%), and food (7%). Epinephrine was administered before ICU admission in 88% of patients with Grade III anaphylaxis and 100% of patients with Grade IV anaphylaxis. Most patients with Grades III and IV anaphylaxes did not receive the recommended dose of i.v. fluid of 30 ml kg within the first 4 h of ICU admission. The time to epinephrine administration was not statistically different between survivors and non-survivors, but non-survivors received a higher dose of epinephrine (median: 5 [3-10] vs 3 [2-7] mg; P<0.0001), which suggests that some forms of anaphylactic shock may be resistant to epinephrine. In multivariate analysis, only lactate concentration at ICU admission was a predictor of death (odds ratio: 1.47 [1.15-1.88]; P=0.002).

Conclusions: Lactate concentration at ICU admission appeared to be the most reliable criterion for assessing prognosis. Epinephrine is widely used during anaphylaxis, but the volume of fluid resuscitation was consistently lower than recommended.

Clinical Trial Registration: NCT04290507.
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http://dx.doi.org/10.1016/j.bja.2020.08.024DOI Listing
December 2020

Coronavirus Disease 2019: Associated Multiple Organ Damage.

Open Forum Infect Dis 2020 Jul 21;7(7):ofaa249. Epub 2020 Jun 21.

Service d'Anesthésie-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.

A 56-year-old man presented a particularly severe and multisystemic case of coronavirus disease 2019 (COVID-19). In addition to the common lung and quite common pulmonary embolism and kidney injuries, he presented ocular and intestinal injuries that, to our knowledge, have not been described in COVID-19 patients. Although it is difficult to make pathophysiological hypotheses about a single case, the multiplicity of injured organs argues for a systemic response to pulmonary infection. A better understanding of physiopathology should feed the discussion about therapeutic options in this type of multifocal damage related to severe acute respiratory syndrome coronavirus 2.
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http://dx.doi.org/10.1093/ofid/ofaa249DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7336548PMC
July 2020

Prevention of thrombotic risk in hospitalized patients with COVID-19 and hemostasis monitoring.

Crit Care 2020 06 19;24(1):364. Epub 2020 Jun 19.

Department of Hematology-Hemostasis, Tours University Hospital, CHRU Tours, Tours, France.

COVID-19 is an infection induced by the SARS-CoV-2 coronavirus, and severe forms can lead to acute respiratory distress syndrome (ARDS) requiring intensive care unit (ICU) management. Severe forms are associated with coagulation changes, mainly characterized by an increase in D-dimer and fibrinogen levels, with a higher risk of thrombosis, particularly pulmonary embolism. The impact of obesity in severe COVID-19 has also been highlighted.In this context, standard doses of low molecular weight heparin (LMWH) may be inadequate in ICU patients, with obesity, major inflammation, and hypercoagulability. We therefore urgently developed proposals on the prevention of thromboembolism and monitoring of hemostasis in hospitalized patients with COVID-19.Four levels of thromboembolic risk were defined according to the severity of COVID-19 reflected by oxygen requirement and treatment, the body mass index, and other risk factors. Monitoring of hemostasis (including fibrinogen and D-dimer levels) every 48 h is proposed. Standard doses of LMWH (e.g., enoxaparin 4000 IU/24 h SC) are proposed in case of intermediate thrombotic risk (BMI < 30 kg/m, no other risk factors and no ARDS). In all obese patients (high thrombotic risk), adjusted prophylaxis with intermediate doses of LMWH (e.g., enoxaparin 4000 IU/12 h SC or 6000 IU/12 h SC if weight > 120 kg), or unfractionated heparin (UFH) if renal insufficiency (200 IU/kg/24 h, IV), is proposed. The thrombotic risk was defined as very high in obese patients with ARDS and added risk factors for thromboembolism, and also in case of extracorporeal membrane oxygenation (ECMO), unexplained catheter thrombosis, dialysis filter thrombosis, or marked inflammatory syndrome and/or hypercoagulability (e.g., fibrinogen > 8 g/l and/or D-dimers > 3 μg/ml). In ICU patients, it is sometimes difficult to confirm a diagnosis of thrombosis, and curative anticoagulant treatment may also be discussed on a probabilistic basis. In all these situations, therapeutic doses of LMWH, or UFH in case of renal insufficiency with monitoring of anti-Xa activity, are proposed.In conclusion, intensification of heparin treatment should be considered in the context of COVID-19 on the basis of clinical and biological criteria of severity, especially in severely ill ventilated patients, for whom the diagnosis of pulmonary embolism cannot be easily confirmed.
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http://dx.doi.org/10.1186/s13054-020-03000-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7303590PMC
June 2020

High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study.

Intensive Care Med 2020 06 4;46(6):1089-1098. Epub 2020 May 4.

Service de Médecine Intensive Réanimation, Nouvel Hôpital Civil, Hôpitaux universitaires de Strasbourg, 1, Place de l'Hôpital, 67091, Strasbourg Cedex, France.

Purpose: Little evidence of increased thrombotic risk is available in COVID-19 patients. Our purpose was to assess thrombotic risk in severe forms of SARS-CoV-2 infection.

Methods: All patients referred to 4 intensive care units (ICUs) from two centers of a French tertiary hospital for acute respiratory distress syndrome (ARDS) due to COVID-19 between March 3rd and 31st 2020 were included. Medical history, symptoms, biological data and imaging were prospectively collected. Propensity score matching was performed to analyze the occurrence of thromboembolic events between non-COVID-19 ARDS and COVID-19 ARDS patients.

Results: 150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPSII 49 [37; 64] points). Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients, mainly pulmonary embolisms (16.7%). 28/29 patients (96.6%) receiving continuous renal replacement therapy experienced circuit clotting. Three thrombotic occlusions (in 2 patients) of centrifugal pump occurred in 12 patients (8%) supported by ECMO. Most patients (> 95%) had elevated D-dimer and fibrinogen. No patient developed disseminated intravascular coagulation. Von Willebrand (vWF) activity, vWF antigen and FVIII were considerably increased, and 50/57 tested patients (87.7%) had positive lupus anticoagulant. Comparison with non-COVID-19 ARDS patients (n = 145) confirmed that COVID-19 ARDS patients (n = 77) developed significantly more thrombotic complications, mainly pulmonary embolisms (11.7 vs. 2.1%, p < 0.008). Coagulation parameters significantly differed between the two groups.

Conclusion: Despite anticoagulation, a high number of patients with ARDS secondary to COVID-19 developed life-threatening thrombotic complications. Higher anticoagulation targets than in usual critically ill patients should therefore probably be suggested.
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http://dx.doi.org/10.1007/s00134-020-06062-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7197634PMC
June 2020

Treatment with a platelet-activating factor receptor antagonist improves hemodynamics and reduces epinephrine requirements, in a lethal rodent model of anaphylactic shock.

Clin Exp Allergy 2020 03 10;50(3):383-390. Epub 2019 Dec 10.

Department of anesthesia and intensive care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France.

Background: In some cases, anaphylactic shock (AS) is still lethal, despite rapid use of epinephrine. High doses of epinephrine are associated with severe complications. Platelet-activating factor (PAF) is secreted in massive amounts during AS, and a high plasma level is correlated with increased AS severity.

Objective: To assess the effect of ABT-491, a PAF-receptor antagonist and possible adjunct treatment, alone or in combination with epinephrine during AS.

Methods: AS was induced by intravenous injection of 1 mg ovalbumin into ovalbumin-sensitized rats. Rats were then randomly assigned to 5 groups (n = 10 per group): SHAM (vehicle only), SHOCK (no treatment), ABT (ABT-491 1 mg/kg), EPI (epinephrine 5 µg as a bolus then 10 µg kg  min by continuous infusion, followed by a reducing protocol) and EPI-ABT (both treatments).

Results: Ovalbumin injection resulted in a severe decrease in mean arterial pressure, left ventricular inotropy (max dP/dt) and left ventricular shortening fraction (LVSF). All rats from the ABT group survived until the end of the experiment. ABT-491 prevented the LVSF decrease observed in the SHOCK group (at T15: ABT 50% ± 11% vs SHOCK 36% ± 9%, P = .01), significantly reduced the dose of epinephrine needed to treat anaphylactic shock (EPI-ABT 314 ± 67 µg/kg vs EPI 475 ± 69 µg/kg, P < .001) and reduced the time to restore basal MAP (ABT 23 ± 7 minutes vs EPI-ABT 13 ± 5 minutes, P < .01).

Conclusions And Clinical Relevance: AS was characterized by early cardiac dysfunction in our model. Treatment with ABT-491 allowed survival until the end of the experiment and reduced cardiac dysfunction. Use of the PAF-R antagonist had a synergistic effect with epinephrine and allowed a significant reduction in epinephrine consumption. Use of PAF-R antagonists during AS could reduce epinephrine-related complications and improve the treatment of epinephrine refractory cases.
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http://dx.doi.org/10.1111/cea.13540DOI Listing
March 2020

Hypersensitivity transfusion reactions to platelet concentrate: a retrospective analysis of the French hemovigilance network.

Transfusion 2020 03 25;60(3):507-512. Epub 2019 Mar 25.

French National Agency for Medicines and Health Products Safety (ANSM), Saint Denis, France.

Background: Among labile blood products, platelet concentrates (PCs) are the leading cause of hypersensitivity transfusion reactions (HTRs). These reactions often lead to interruption of PC transfusion and can result in a prolonged transfusion process leading to significant morbidity and use of premedication and close monitoring for patients with a history of allergic transfusion reactions. The French hemovigilance database is one of the largest standardized databases providing information on HTRs following administration of labile blood products. In this study, we analyzed this database to assess the relative risk of HTR for each type of PC.

Study Design And Methods: HTRs following PC transfusion were retrospectively extracted from the e-Fit Hemovigilance database of the French National Agency for Medicines and Health Products Safety (ANSM). Frequencies were calculated using the number of specific PCs transfused.

Results: Between 2008 and 2014, the overall estimated incidence of HTRs following PC administration was calculated at 232 HTRs per 100,000 PCs transfused. The rate of HTRs was significantly higher with apheresis PC (337/100,000) than with buffy-coat PC (94/100,000). Platelets in additive solutions (PAS) were associated with a significantly lower frequency of HTRs when compared with PCs in native plasma. Amotosalen/UVA- PCs (APCs and BCPCs) which are always in PAS in France, exhibited the lowest frequency of HTRs when compared with their corresponding PCs in native plasma or in PAS (p < 10 in all comparisons).

Conclusion: Our results showed that the type of PC and its processing may have an impact on the risk of HTR.
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http://dx.doi.org/10.1111/trf.15275DOI Listing
March 2020

Adjusted calculation model of heparin management during cardiopulmonary bypass in obese patients: A randomised controlled trial.

Eur J Anaesthesiol 2018 08;35(8):613-620

From the Department of Anesthesiology and Intensive Care (MV, EH, TW, FL, CT, OC, P-MM, AS), Laboratory of Haemostasis (LG, LS), Department of Cardiac Surgery, NHC (THM) and Department of BioStatistics (FS), Federation de Medecine Translationelle, University Hospital, Strasbourg, France.

Background: Anticoagulation during cardiopulmonary bypass (CPB) is usually adapted to total body weight (TBW). This may be inaccurate in obese patients and lead to heparin overdose with a risk of bleeding.

Objectives: To validate the efficacy and safety of an adjusted calculation model of heparin dosing based on ideal body weight (IBW) rather than TBW in obese CPB patients, with an expected target mean plasma heparin concentration of 4.5 IU ml after onset of CPB in the experimental group.

Design: Randomised controlled study.

Setting: University hospital.

Patients: Sixty obese patients (BMI ≥ 30 kg m) scheduled for CPB were included from January to June 2016.

Interventions: Patients received a bolus dose of unfractionated heparin of either 300 IU kg of TBW or 340 IU kg of IBW before onset of CPB. Additional adjusted boluses were injected to maintain an activated clotting time (ACT) of at least 400 s.

Main Outcome Measures: Plasma heparin concentration and ACT were measured at different time points. Total heparin doses and transfusion requirements were recorded.

Results: The target heparin concentration of 4.5 IU ml was reached in the IBW group at the onset of CPB and maintained at all time points during CPB. Heparin concentrations were significantly higher in the TBW group after the bolus (6.52 ± 0.97 vs. 4.54 ± 1.13 IU ml, P < 0.001) and after cardioplegia (5.10 ± 1.03 vs. 4.31 ± 1.00 IU ml, P = 0.02). Total heparin doses were significantly higher in the TBW group. Mean ACT was significantly lower in the IBW group but remained over 400 s during CPB. The correlation between heparin and ACT was poor. Peri-operative bleeding and transfusion requirements were comparable. No thrombotic event occurred in the CPB circuit.

Conclusion: The current IBW-adjusted regimen of heparin administration may be used efficiently in obese CPB patients, thereby avoiding overdose which cannot be accurately assessed by ACT monitoring alone.

Trial Registration: ClinicalTrials.gov identifier: NCT02675647.
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http://dx.doi.org/10.1097/EJA.0000000000000784DOI Listing
August 2018

Epinephrine but not vasopressin attenuates the airway response to anaphylactic shock in rats.

Exp Lung Res 2017 04 25;43(3):158-166. Epub 2017 May 25.

b Service d'Anesthésie-Réanimation Chirurgicale, Pôle Anesthésie, Réanimations Chirurgicales, SAMU-SMUR, Nouvel Hôpital Civil , Hôpitaux Universitaires de Strasbourg , Strasbourg , France.

Purpose: The two life-threatening signs of anaphylactic shock (AS) are severe arterial hypotension and bronchospasm. Guidelines recommend epinephrine as first-line treatment. Arginine vasopressin (AVP) has been proposed as an alternative if epinephrine does not correct arterial hypotension. These two drugs may have beneficial, neutral or deleterious effects on airflow either directly or by modifying factors that regulate vasodilatation and/or edema in the bronchial wall.

Aim Of The Study: To compare the effects of epinephrine and AVP on airflow and airway leakage in a rat model of AS.

Materials And Methods: Thirty-two ovalbumin-sensitized rats were randomized into four groups: control (CON), AS without treatment (OVA), AS treated with epinephrine (EPI), and AS treated with AVP (AVP). Mean arterial pressure (MAP), respiratory resistance and elastance and microvascular leakage in the airways were measured.

Results: All OVA rats died within 20 minutes following ovalbumin injection. Ovalbumin induced severe arterial hypotension and airway obstruction (221 ± 36 hPa.s.L vs. vehicle 52 ± 8 hPa.s.L; p < 0.0001) associated with microvascular leakage distributed throughout the trachea, bronchi and intra-pulmonary airways. EPI and AVP extended survival time; EPI restored a higher level of MAP than AVP. Airway obstruction was attenuated by epinephrine (146 ± 19 hPa.s.L; p < 0.0001), but not by AVP (235 ± 58 hPa.s.L; p = 0.42).

Conclusions: Epinephrine was superior to AVP for alleviating the airway response in a rat model of AS. When bronchospasm and severe arterial hypotension are present during AS, epinephrine should be the drug of choice.
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http://dx.doi.org/10.1080/01902148.2017.1323981DOI Listing
April 2017

Hypersensitivity transfusion reactions due to IgA deficiency are rare according to French hemovigilance data.

J Allergy Clin Immunol 2017 09 13;140(3):884-885. Epub 2017 Apr 13.

Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, Strasbourg, France. Electronic address:

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http://dx.doi.org/10.1016/j.jaci.2017.03.029DOI Listing
September 2017

Allergy to local anesthetics: Reality or myth?

Presse Med 2016 Sep 1;45(9):753-7. Epub 2016 Jul 1.

CHU de Montpellier, hôpital Arnaud-de-Villeneuve, division allergie, département de pneumologie, 34295 Montpellier, France.

The incidence of allergic reactions to local anesthetics is low. Most cases involve a psychogenic reaction rather than an allergic reaction. Additives and preservatives added to local anesthetics may cause allergic reactions. Vascular resorption of epinephrine-containing local anesthetics may produce cardiovascular signs similar to an allergic reaction. Diagnosis of allergy to local anesthetics must be established by skin testing and provocative challenge.
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http://dx.doi.org/10.1016/j.lpm.2016.05.011DOI Listing
September 2016

Diagnostic procedure after an immediate hypersensitivity reaction in the operating room.

Presse Med 2016 Sep 30;45(9):784-90. Epub 2016 Jun 30.

Hôpitaux universitaires de Strasbourg, département d'anesthésie-réanimation, 67000 Strasbourg, France.

The diagnosis of a perioperative allergic reaction is based on clinical features associated with a suggestive timeline, the exclusion of other diagnoses, elevated concentrations of degranulation markers (histamine, tryptase), and positive allergy assessments (skin tests, specific IgE). After initiating appropriate treatment, the anesthesiologist should take blood samples to measure histamine and tryptase concentrations just after the reaction and repeat them 1-2hours later to validate the diagnosis of immediate hypersensitivity. A delayed measurement of basal tryptase is useful to rule out mastocytosis and to interpret moderate tryptase levels. The anesthesiologist must inform the patient of the reaction to obtain adhesion and consent to subsequent investigations and must record the timing of the reaction and of the blood sampling, the possible causal agents, and the treatment administered. These data must be shared with the laboratory and the allergist. An adverse drug reaction report must be filed. The gold standard for allergy assessment is skin testing. These tests should be done in an appropriate facility, with experienced staff and in compliance with current guidelines. Specific IgE assays and cellular assays can help when clinical features and skin tests are discordant. Provocation tests are sometimes required. After allergy assessment, the safest protocol for subsequent anesthesia is determined in collaboration with the anesthesiologist. The patient must be informed and carry an allergy alert card.
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http://dx.doi.org/10.1016/j.lpm.2016.05.016DOI Listing
September 2016

Epidemiology of perioperative anaphylaxis.

Presse Med 2016 Sep 12;45(9):758-67. Epub 2016 May 12.

Nouvel Hôpital Civil, hôpitaux universitaires de Strasbourg, service d'anesthésie-réanimation chirurgicale, 1, place de l'Hôpital, BP 426, 67091 Strasbourg cedex, France.

Anaphylactic reactions may be either of immune (allergy, usually IgE-mediated, sometimes IgG-mediated) or non-immune origin. The incidence of anaphylactic reactions during anaesthesia varies between countries ranging from 1/1250 to 1/18,600 per procedure. In France, the estimated incidence of allergic reactions is 100.6 [76.2-125.3]/million procedure with a high female predominance (male: 55.4 [42.0-69.0], female: 154.9 [117.2-193.1]). The proportion of IgE-mediated allergic reactions seems to be relatively similar between countries, ranging from 50 to 60%. Substantial geographical variability regarding the different drugs or substances involved is reported. Reactions involving neuromuscular blocking agents are a major cause in several countries but are less frequently reported in the United States or Denmark. Reactions involving antibiotics, dyes or chlorhexidine are reported with a high and sometimes increasing frequency in most series. Reactions to latex are rapidly decreasing as a result of primary and secondary prevention policy. Regional differences are a strong incentive for repeated epidemiological surveys in different countries.
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http://dx.doi.org/10.1016/j.lpm.2016.02.024DOI Listing
September 2016

Post-intubation tracheal rupture: poor healing of the tracheal wall.

Can J Anaesth 2014 Apr 28;61(4):357-61. Epub 2014 Jan 28.

Pôle Anesthésie - Réanimations Chirurgicales - SAMU, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.

Purpose: To describe tracheal rupture after orotracheal intubation assisted by a tracheal tube introducer.

Clinical Features: A 73-yr-old morbidly obese female patient with a history of hypertension underwent a total knee replacement. There were no anticipated signs of difficult intubation. Orotracheal intubation was attempted twice by direct laryngoscopy, and a Boussignac bougie was used as a tube exchanger for the second attempt. Seven hours after tracheal extubation, the patient became dyspneic and showed a large subcutaneous emphysema. A chest x-ray and computerized tomography scan revealed rupture of the posterior tracheal wall. The distal part of the injury was 26.5 cm from the patient's teeth and 0.5 cm from the carina (i.e., beyond the normal location of the tracheal tube tip) and extended to the origin of the right main bronchus, where the tip of the Boussignac bougie was probably pushed. Formation of an endotracheal sac occurred during the first two weeks after intubation, accompanied by dyspnea and alveolar hypoventilation, but symptoms resolved favourably with conservative management.

Conclusion: The tracheal rupture was attributed to airway manipulations, and the distal location of the lesion suggests that the cause was the Boussignac bougie rather than the tracheal tube. Long-term healing of the injury was satisfactory, although the patient continued to complain of dyspnea one year after the rupture.
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http://dx.doi.org/10.1007/s12630-014-0114-0DOI Listing
April 2014