Publications by authors named "Emmanuel Samain"

50 Publications

Minimum effective concentration of ropivacaine for 90% ultrasound-guided axillary brachial plexus block, with or without intravenous dexamethasone.

J Clin Anesth 2021 Dec 28;75:110468. Epub 2021 Jul 28.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France. Electronic address:

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http://dx.doi.org/10.1016/j.jclinane.2021.110468DOI Listing
December 2021

Individual versus collective debriefing after interprofessional training course simulation: The randomised DEBRIEF-SIM trial.

Anaesth Crit Care Pain Med 2021 04 17;40(2):100828. Epub 2021 Mar 17.

Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besancon, F-25000 Besancon, France; SFR FED 4234, EA 3920, University of Franche-Comté, F-25000 Besancon, France.

Introduction: Debriefing is a critical phase in simulation-based education that is extremely time-consuming for the instructors. The aim of the study was to assess whether a collective debriefing was non-inferior to an individual debriefing to improve learning outcomes after a simulation session.

Methods: This randomised controlled multicentre non-inferiority study included pairs comprising one resident and one student nurse in anaesthesia. Each pair underwent two sessions of a simulated life-threatening emergency held at a 6-week interval. Six participant pairs underwent simulation sessions every half-day of training. The debriefing performed after the first session was either individual (1 debriefing by pair; individual group) or collective (1 debriefing by 6 pairs; collective group). The primary outcome was the evolution of a 34-parameter technical skill score (Delta-TSS-34) between the two simulation sessions. The non-inferiority margin was 5. The change in the Anaesthetists' Non-Technical Skills score (Delta-ANTS), and the debriefing duration per participant pair were secondary endpoint measures.

Results: Respectively 23 and 21 pairs were included in the collective and individual groups. Delta-TSS-34 was non-inferior in the collective group compared to the individual group (mean intergroup difference [95% confidence interval]: 2.71 [0.44-4.98]). Delta-ANTS did not significantly differ between the two groups (median [interquartile range]: 22 [10-37] versus 25 [17-35], p = 0.57; respectively in the collective and individual groups). The debriefing duration per participant pair was significantly lower in the collective group (10 [10-11] min versus 27 [25-28] min; p < 0.001).

Conclusion: Collective debriefing was non-inferior to individual debriefing to improve learning outcomes after simulation of medical emergencies and allows a significant reduction in the time dedicated to the debriefing.
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http://dx.doi.org/10.1016/j.accpm.2021.100828DOI Listing
April 2021

Transnasal humidified rapid-insufflation ventilatory exchange during rapid sequence induction in children.

Anaesth Crit Care Pain Med 2021 04 4;40(2):100817. Epub 2021 Mar 4.

Department of Anaesthesia and Intensive Care, Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France; Université de Paris, Paris, France; DHU PROTECT. Robert Debré Hospital, 48, boulevard Sérurier, 75019 Paris, France. Electronic address:

Background: The objective of this study was to measure the incidence of arterial oxygen desaturation during rapid sequence induction intubation in children following apnoeic oxygenation via transnasal humidified rapid-insufflation ventilatory exchange (THRIVE).

Methods: In this prospective observational study, arterial desaturation < 95% SaO before intubation was recorded following apnoeic RSI combining an intravenous hypnotic agent, suxamethonium and THRIVE (used during the apnoeic period). The incidence of desaturation was calculated in the whole cohort and according to patients' age (older or younger than 1 year).

Results: Complete data were collected for 79 patients, 1 day to 15 years of age. Nine patients (11.4%) exhibited arterial desaturation before tracheal intubation and received active facemask ventilation. Patients exhibiting desaturation were more likely to be less than 1 year of age (9/9, (100%) versus 37/70, (52.9%); P = 0.005), to be reported as difficult intubations (5/9, (55.6%) versus 1/70, (1.4%), p < 0.001), and to have regurgitation at induction (2/9, (22.2%) versus 0/70, (0%), p = 0.01).

Conclusions: Results of the current study indicated that almost 91% of RSI can be performed without desaturation when THRIVE is used. A comparative controlled study is required to confirm these findings. Specific situations and conditions limiting the efficacy of THRIVE during RSI should also be investigated.
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http://dx.doi.org/10.1016/j.accpm.2021.100817DOI Listing
April 2021

Semi-elemental versus polymeric formula for enteral nutrition in brain-injured critically ill patients: a randomized trial.

Crit Care 2021 01 20;25(1):31. Epub 2021 Jan 20.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, 25000, Besancon, France.

Background: The properties of semi-elemental enteral nutrition might theoretically improve gastrointestinal tolerance in brain-injured patients, known to suffer gastroparesis. The purpose of this study was to compare the efficacy and tolerance of a semi-elemental versus a polymeric formula for enteral nutrition (EN) in brain-injured critically ill patients.

Methods: Prospective, randomized study including brain-injured adult patients [Glasgow Coma Scale (GCS) ≤ 8] with an expected duration of mechanical ventilation > 48 h.

Intervention: an enteral semi-elemental (SE group) or polymeric (P group) formula. EN was started within 36 h after admission to the intensive care unit and was delivered according to a standardized nurse-driven protocol. The primary endpoint was the percentage of patients who received both 60% of the daily energy goal at 3 days and 100% of the daily energy goal at 5 days after inclusion. Tolerance of EN was assessed by the rate of gastroparesis, vomiting and diarrhea.

Results: Respectively, 100 and 95 patients were analyzed in the SE and P groups: Age (57[44-65] versus 55[40-65] years) and GCS (6[3-7] versus 5[3-7]) did not differ between groups. The percentage of patients achieving the primary endpoint was similar (46% and 48%, respectively; relative risk (RR) [95% confidence interval (CI)] = 1.05 (0.78-1.42); p = 0.73). The mean daily energy intake was, respectively, 20.2 ± 6.3 versus 21.0 ± 6.5 kcal/kg/day (p = 0.42). Protein intakes were 1.3 ± 0.4 versus 1.1 ± 0.3 g/kg/day (p < 0.0001). Respectively, 18% versus 12% patients presented gastroparesis (p = 0.21), and 16% versus 8% patients suffered from diarrhea (p = 0.11). No patient presented vomiting in either group.

Conclusion: Semi-elemental compared to polymeric formula did not improve daily energy intake or gastrointestinal tolerance of enteral nutrition.

Trial Registration: EudraCT/ID-RCB 2012-A00078-35 (registered January 17, 2012).
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http://dx.doi.org/10.1186/s13054-020-03456-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818740PMC
January 2021

Postoperative Neurocognitive Disorders After Closed-Loop Versus Manual Target Controlled-Infusion of Propofol and Remifentanil in Patients Undergoing Elective Major Noncardiac Surgery: The Randomized Controlled Postoperative Cognitive Dysfunction-Electroencephalographic-Guided Anesthetic Administration Trial.

Anesth Analg 2021 10;133(4):837-847

From the Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France.

Background: The aim of the study was to investigate whether closed-loop compared to manual bispectral index (BIS)-guided target-controlled infusion of propofol and remifentanil could decrease the incidence of postoperative neurocognitive disorders after elective major noncardiac surgery.

Methods: Patients aged >50 admitted for elective major noncardiac surgery were included in a single-blind randomized (ratio 2:1) trial. The anesthetic protocol was allocated by randomization into either closed-loop or manual BIS-guided propofol and remifentanil titration. The BIS target range was 40-60. All patients had cognitive assessment the day before surgery and within 72 hours after surgery using a battery of neuropsychological tests. The primary outcome was the rate of postoperative neurocognitive disorders. Postoperative neurocognitive disorders were defined as a decrease >20% from baseline on at least 3 scores. Intergroup comparison of the primary outcome was performed using the χ2 test.

Results: A total of 143 and 61 patients were included in the closed-loop and manual groups, respectively (age: 66 [8] vs 66 [9] years). The primary outcome was observed in 18 (13%) and 10 (16%) patients of the closed-loop and manual groups, respectively (relative risk [95% confidence interval {CI}], 0.77 [0.38-1.57], P = .47). Intraoperative propofol consumption was lower (4.7 [1.4] vs 5.7 [1.4] mg·kg-1·h-1, mean difference [MD] [95% CI], -0.73 [-0.98 to -0.48], P < .0001) and the proportion of time within the BIS target range higher (84 [77-89] vs 74 [54-81]%, MD [95% CI], 0.94 [0.67-1.21], P < .0001) in the closed-loop group.

Conclusions: Closed-loop compared to manual BIS-guided total intravenous anesthesia provided a significant reduction in episodes of an excessive depth of anesthesia while decreasing intraoperative propofol requirement but no evidence for a reduction of the incidence of postoperative neurocognitive disorders after elective major noncardiac surgery was observed.
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http://dx.doi.org/10.1213/ANE.0000000000005278DOI Listing
October 2021

Neck ultrasound to improve risk assessment for difficult tracheal intubation in the operating room: The TUBECHO case-control prospective observational pilot study.

J Clin Anesth 2021 Feb 15;68:110101. Epub 2020 Oct 15.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Besancon, France; EA 3920, University of Franche-Comte, Besancon, France. Electronic address:

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http://dx.doi.org/10.1016/j.jclinane.2020.110101DOI Listing
February 2021

A national healthcare response to intensive care bed requirements during the COVID-19 outbreak in France.

Anaesth Crit Care Pain Med 2020 Dec 5;39(6):709-715. Epub 2020 Oct 5.

Department of Anaesthesiology and Critical Care Medicine, Lapeyronie University Hospital and Montpellier University. INSERM unit 1051, Montpellier Neurosciences Institute, Montpellier, France.

Background: Whereas 5415 Intensive Care Unit (ICU) beds were initially available, 7148 COVID-19 patients were hospitalised in the ICU at the peak of the outbreak. The present study reports how the French Health Care system created temporary ICU beds to avoid being overwhelmed.

Methods: All French ICUs were contacted for answering a questionnaire focusing on the available beds and health care providers before and during the outbreak.

Results: Among 336 institutions with ICUs before the outbreak, 315 (94%) participated, covering 5054/5531 (91%) ICU beds. During the outbreak, 4806 new ICU beds (+95% increase) were created from Acute Care Unit (ACU, 2283), Post Anaesthetic Care Unit and Operating Theatre (PACU & OT, 1522), other units (374) or real build-up of new ICU beds (627), respectively. At the peak of the outbreak, 9860, 1982 and 3089 ICU, ACU and PACU beds were made available. Before the outbreak, 3548 physicians (2224 critical care anaesthesiologists, 898 intensivists and 275 from other specialties, 151 paediatrics), 1785 residents, 11,023 nurses and 6763 nursing auxiliaries worked in established ICUs. During the outbreak, 2524 physicians, 715 residents, 7722 nurses and 3043 nursing auxiliaries supplemented the usual staff in all ICUs. A total number of 3212 new ventilators were added to the 5997 initially available in ICU.

Conclusion: During the COVID-19 outbreak, the French Health Care system created 4806 ICU beds (+95% increase from baseline), essentially by transforming beds from ACUs and PACUs. Collaboration between intensivists, critical care anaesthesiologists, emergency physicians as well as the mobilisation of nursing staff were primordial in this context.
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http://dx.doi.org/10.1016/j.accpm.2020.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534597PMC
December 2020

Clinical effectiveness of ultrasound-guided dual transversus abdominis plane block for postoperative analgesia in open abdominal aortic surgery patients: The randomised, double-blind ETAP trial.

Eur J Anaesthesiol 2020 09;37(9):821-823

From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besancon (JC, ED, TL, VS, SP-F, ES, GB), EA 3920, Bourgogne Franche-Comte University (LSdM, SP-F, ES, GB), Department of Vascular Surgery (LSdM) and Clinical Methodology Center, University Hospital of Besancon, Besancon, France (MP).

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http://dx.doi.org/10.1097/EJA.0000000000001240DOI Listing
September 2020

Blood glucose control management in critically ill adult patients: Results of a French nationwide practice survey.

Anaesth Crit Care Pain Med 2020 06 21;39(3):447-449. Epub 2020 May 21.

Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3, boulevard Alexander Fleming, 25000 Besancon, France; EA 3920, Bourgogne Franche-Comte University, 3, boulevard Alexander Fleming, 25000 Besancon, France. Electronic address:

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http://dx.doi.org/10.1016/j.accpm.2020.04.017DOI Listing
June 2020

Impact of post-procedural glycemic variability on cardiovascular morbidity and mortality after transcatheter aortic valve implantation: a post hoc cohort analysis.

Cardiovasc Diabetol 2019 03 11;18(1):27. Epub 2019 Mar 11.

EA3920, University of Franche-Comte, 25000, Besancon, France.

Background: Glycemic variability is associated with worse outcomes after cardiac surgery, but the prognosis value of early glycemic variability after transcatheter aortic valve implantation is not known. This study was therefore designed to analyze the prognosis significance of post-procedural glycemic variability within 30 days after transcatheter aortic valve implantation.

Methods: A post hoc analysis of patients from our center included in the FRANCE and FRANCE-2 registries was conducted. Post-procedural glycemic variability was assessed by calculating the mean daily δ blood glucose during the first 2 days after transcatheter aortic valve implantation. Major complications within 30 days were death, stroke, myocardial infarction, acute heart failure, and life-threatening cardiac arrhythmias.

Results: We analyzed 160 patients (age (median [interquartile] = 84 [80-88] years; diabetes mellitus (n) = 41 (26%) patients; logistic Euroscore = 20 [12-32]). The median value of mean daily δ blood glucose was 4.3 mmol l. The rate of major complications within 30 days after procedure among patients with the lowest quartile of glycemic variability was 12%, increasing from 12 to 26%, and 39% in the second, third, and fourth quartiles, respectively. In multivariate analysis, glycemic variability was independently associated with an increased risk of major complications within 30 days after the procedure (odds ratio [95% CI] = 1.83 [1.19-2.83]; p = 0.006).

Conclusions: This study showed that post-procedural glycemic variability was associated with an increased risk of major complications within 30 days after transcatheter aortic valve implantation. Trial registration Clinical trial registration number https://www.clinicaltrials.gov/ ; identifier: NCT02726958; date: April 4th, 2016.
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http://dx.doi.org/10.1186/s12933-019-0831-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6410509PMC
March 2019

Effect of age of transfused red blood cells on neurologic outcome following traumatic brain injury (ABLE-tbi Study): a nested study of the Age of Blood Evaluation (ABLE) trial.

Can J Anaesth 2019 06 26;66(6):696-705. Epub 2019 Feb 26.

CHU de Québec - Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma - Emergency - Critical Care Medicine, Université Laval, Quebec City, QC, Canada.

Background: Anemia is common in critically ill patients with traumatic brain injury, and often requires red blood cell transfusion. Studies suggest that prolonged storage causes lesions of the red blood cells, including a decreased ability to carry oxygen. Considering the susceptibility of the brain to hypoxemia, victims of traumatic brain injury may thus be more vulnerable to exposure to older red blood cells.

Methods: Our study aimed to ascertain whether the administration of fresh red blood cells (seven days or less) results in a better neurologic outcome compared with standard red blood cells in critically ill patients with traumatic brain injury requiring transfusion. The Age of Blood Evaluation in traumatic brain injury (ABLE-tbi) study was a nested study within the ABLE study (ISRCTN44878718). Our primary outcome was the extended Glasgow Outcome Scale (GOSe) at six months.

Results: In the ABLE study, 217 subjects suffered a traumatic brain injury: 110 in the fresh group, and 107 in the standard group. In the fresh group, 68 (73.1%) of the patients had an unfavourable neurologic outcome (GOSe ≤ 4) compared with 60 (64.5%) in the standard group (P = 0.21). Using a sliding dichotomy approach, we observed no overall effect of fresh red blood cells on neurologic outcome (odds ratio [OR], 1.34; 95% confidence interval [CI], 0.72 to 2.50; P = 0.35) but observed differences across prognostic bands with a decreased odds of unfavourable outcome in patients with the best prognosis at baseline (OR, 0.33; 95% CI, 0.11 to 0.96; P = 0.04) but an increased odds in those with intermediate and worst baseline prognosis (OR, 5.88; 95% CI,1.66 to 20.81; P = 0.006; and OR, 1.67; 95% CI, 0.53 to 5.30; P = 0.38, respectively).

Conclusion: Overall, transfusion of fresh red blood cells was not associated with a better neurologic outcome at six months in critically ill patients with traumatic brain injury. Nevertheless, we cannot exclude a differential effect according to the patient baseline prognosis.

Trial Registration: ABLE study (ISRCTN44878718); registered 22 August, 2008.
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http://dx.doi.org/10.1007/s12630-019-01326-7DOI Listing
June 2019

Clinical effectiveness of single dose of intravenous dexamethasone on the duration of ropivacaine axillary brachial plexus block: the randomized placebo-controlled ADEXA trial.

Reg Anesth Pain Med 2019 03;44(3)

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, Bourgogne Franche-Comte University, Besancon, France.

Background And Objectives: The effect of intravenous dexamethasone on the duration of axillary plexus block performed using ropivacaine is not described. The aim of this study is to assess the effect of intravenous dexamethasone on the duration of axillary plexus block analgesia after distal upper arm surgery.

Methods: In this prospective, randomized, placebo-controlled, double-blinded trial, consenting patients scheduled for hand or forearm surgery under ultrasound-guided axillary plexus block performed using 0.5 mL/kg of 0.475% ropivacaine, were randomized to receive an intravenous injection of either 8 mg/2 mL of dexamethasone (Dexa group) or 2 mL of saline (Control). The primary outcome was the time of first analgesic intake after axillary block. Secondary outcomes included motor or sensory block duration, total use of postoperative analgesics, and block-related complications.

Results: Among the 98 patients included, 6 and 2 patients did not require postoperative analgesic intake in Dexa and Control groups, respectively (p=0.06). The time of first analgesic intake was significantly longer in the Dexa (20.9±9.3 hours) than in the Control group (14.7±6.6 hours, p<0.0004). Motor and sensory recovery occurred significantly later, and total analgesic consumption was lower in the Dexa than in the Control group. No nerve complication related to intravenous dexamethasone injection was recorded.

Conclusions: This study showed that intravenous dexamethasone delayed for 6 hours the time to first analgesic intake after upper arm surgery under axillary plexus block performed with the long-lasting local anesthetic ropivacaine. This suggests that intravenous dexamethasone could be an interesting adjuvant to axillary plexus block.

Trial Registration Number: NCT02862327.
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http://dx.doi.org/10.1136/rapm-2018-100035DOI Listing
March 2019

Impact of intravenous exenatide infusion for perioperative blood glucose control on myocardial ischemia-reperfusion injuries after coronary artery bypass graft surgery: sub study of the phase II/III ExSTRESS randomized trial.

Cardiovasc Diabetol 2018 11 1;17(1):140. Epub 2018 Nov 1.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, and, EA3920 and SFR-FED 4234 INSERM, University of Franche-Comte, 3 bvd Alexander Fleming, 25000, Besançon, France.

Background: The aim of the study was to investigate whether intravenous (iv) infusion of exenatide, a synthetic GLP-1 receptor agonist, could provide a protective effect against myocardial ischemia-reperfusion injury after coronary artery bypass graft (CABG) surgery.

Methods: A sub study analysis of patients > 18 years admitted for elective CABG and included in the ExSTRESS trial was conducted. Patients were randomized to receive either iv exenatide (1-h bolus of 0.05 µg min followed by a constant infusion of 0.025 µg min) (exenatide group) or iv insulin therapy (control group) for blood glucose control (target range 100-139 mg dl) during the first 48 h after surgical incision. All serum levels of troponin I measured during routine care in the Cardiac Surgery ICU were recorded. The primary outcome was the highest value of plasma concentration of troponin I measured between 12 and 24 h after ICU admission. The proportion of patients presenting an echocardiographic left ventricular ejection fraction (LVEF) > 50% at the follow-up consultation was compared between the two groups.

Results: Finally, 43 and 49 patients were analyzed in the control and exenatide groups, respectively {age: 69 [61-76] versus 71 [63-75] years; baseline LVEF < 50%: 6 (14%) versus 16 (32%) patients; on-pump surgery: 29 (67%) versus 33 (67%) patients}. The primary outcome did not significantly differ between the two groups (3.34 [1.06-6.19] µg l versus 2.64 [1.29-3.85] µg l in the control and exenatide groups, respectively; mean difference (MD) [95% confidence interval (95% CI)] 0.16 [- 0.25; 0.57], p = 0.54). The highest troponin value measured during the first 72 h in the ICU was 6.34 [1.36-10.90] versus 5.04 [2.39-7.18] µg l, in the control and exenatide groups respectively (MD [95% CI] 0.20 [- 0.22; 0.61], p = 0.39). At the follow-up consultation, 5 (12%) versus 8 (16%) patients presented a LVEF < 50% in the control and in the exenatide groups respectively (relative risk [95% CI] 0.68 [0.16; 2.59], p = 0.56).

Conclusions: Postoperative iv exenatide did not provide any additional cardioprotective effect compared to iv insulin in low-risk patients undergoing scheduled CABG surgery. Trial registration ClinicalTrials.gov Identifier NCT01969149, date of registration: January 7th, 2015; EudraCT No. 2009-009254-25 A, date of registration: January 6th, 2009.
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http://dx.doi.org/10.1186/s12933-018-0784-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6211400PMC
November 2018

Early post-operative cognitive dysfunction after closed-loop versus manual target controlled-infusion of propofol and remifentanil in patients undergoing elective major non-cardiac surgery: Protocol of the randomized controlled single-blind POCD-ELA trial.

Medicine (Baltimore) 2018 Oct;97(40):e12558

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, University of Franche-Comte, Besancon.

Introduction: Post-operative cognitive dysfunction (POCD) is frequent in patients older than 60 years undergoing major non-cardiac surgery, and increases both morbidity and mortality. Anesthetic drugs may exert neurotoxic effects and contribute to the genesis of POCD. The hypothesis of the POCD-ELA trial was that closed-loop target-controlled infusion of propofol and remifentanil could reduce the occurrence of POCD by decreasing the risk of excessive depth of anesthesia and the dose of anesthetic drugs.

Methods And Analysis: We designed a single-center, single-blind, randomized, controlled, parallel trial and aim to include 204 patients aged >60 years undergoing elective major non-cardiac surgery. Patients will be randomized to receive closed-loop versus manual target-controlled infusion of propofol and remifentanil guided by bispectral index monitoring. Cognitive assessment will be performed the day before surgery (baseline) and within 72 hours after surgery, using a battery of validated neuropsychological tests. The primary outcome is the incidence of POCD within 72 hours after surgery. POCD is defined as a Z-score value > 1.96 for at least 2 different tests or a Z-score composite value >1.96. The calculation of the Z-score is based on data from an age-matched control population who did not undergo surgery or general anesthesia.

Ethics And Dissemination: This study was approved by the Ethics Committee (Comité de Protection des Personnes Est-II) and authorized by the French Health Products Agency (Agence Nationale de Sécurité des Médicaments, Saint-Denis, France). The University Hospital of Besancon is the trial sponsor and the holder of all data and publication rights. Results of the study will be submitted for publication in a peer-review international medical journal and for presentation in abstract (oral or poster) in international peer-reviewed congresses.

Registration: The trial is registered with ClinicalTrials.gov (Identifier: NCT02841423, principal investigator: Prof Emmanuel Samain, date of registration: July 22, 2016). Last amendment of protocol: version 8.0 April 2018.
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http://dx.doi.org/10.1097/MD.0000000000012558DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6200461PMC
October 2018

Long-term compliance with a validated intravenous insulin therapy protocol in cardiac surgery patients: a quality improvement project.

Int J Qual Health Care 2018 Dec;30(10):817-822

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 3 bvd Alexander Fleming, Besancon, France.

Quality Problem: Safe and efficient blood glucose (BG) level control after cardiac surgery relies on an intensive care unit (ICU) team-based approach, including implementation of a dynamic insulin therapy protocol (ITP). Long-term compliance with such a complex protocol is poorly addressed in the literature. The aim of this study was to assess the long-term compliance of nurses with the ITP, 7 years after its implementation in the ICU.

Initial Assessment: A professional practice evaluation, integrated in a process of quality improvement program, was retrospectively conducted on 224 consecutive cardiac surgery patients over a 6-month period (PHASE 1). The timing of BG measurements and the insulin infusion rate adjustments (primary endpoints) were correctly performed according to protocol requirements in 35 and 53% of the cases, respectively.

Choice Of Solution And Implementation: After systemic analysis of the causes of protocol deviations, four corrective measures aiming at improving both physician and nurse adherence to the protocol were implemented in the ICU.

Evaluation: Evaluation of 104 patients in PHASE 2 showed a significant improvement in both the timing of BG measurements (83 %, P < 0.001 vs. PHASE 1), and insulin infusion rate adjustments (76%, P < 0.001).

Lessons Learned: Seven years after the implementation of a dynamic insulin infusion protocol, major protocol deviations were observed. Identification of several causes after a professional practice evaluation and the implementation of simple corrective measures restored a high level of nurse compliance.
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http://dx.doi.org/10.1093/intqhc/mzy112DOI Listing
December 2018

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.

Anaesth Crit Care Pain Med 2018 Aug 19;37(4):367-374. Epub 2018 Mar 19.

Department of anaesthesia, institut Gustave-Roussy, Villejuif, France.

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.
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http://dx.doi.org/10.1016/j.accpm.2018.02.021DOI Listing
August 2018

Pectoral nerve block and persistent pain following breast cancer surgery: an observational cohort study.

Minerva Anestesiol 2018 06 15;84(6):769-771. Epub 2018 Feb 15.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besançon, Besançon, France.

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http://dx.doi.org/10.23736/S0375-9393.18.12544-2DOI Listing
June 2018

Clinical Effectiveness of Intravenous Exenatide Infusion in Perioperative Glycemic Control after Coronary Artery Bypass Graft Surgery: A Phase II/III Randomized Trial.

Anesthesiology 2017 11;127(5):775-787

From the Department of Anesthesiology and Intensive Care Medicine (G.B., M.B., G.F., B.B., E.S., S.P.-F.), EA 3920 (G.B., A.P., L.S., E.S., S.C., S.P.-F.), Department of Cardiothoracic Surgery (A.P., S.C.), Clinical Methodology Center (F.M., M.P.), and Department of Vascular Surgery (L.S.), University Hospital of Besancon, Chrono-environement Laboratory, UMR6249 CNRS (F.M.), and SFR-FED 4234 INSERM (E.S., S.P.-F.), University of Franche-Comte, Besancon, France.

Background: We aimed to assess the clinical effectiveness of intravenous exenatide compared to insulin in perioperative blood glucose control in coronary artery bypass grafting surgery patients.

Methods: Patients more than 18 yr old admitted for elective coronary artery bypass grafting were included in a phase II/III nonblinded randomized superiority trial. Current insulin use and creatinine clearance of less than 60 ml/min were exclusion criteria. Two groups were compared: the exenatide group, receiving exenatide (1-h bolus of 0.05 µg/min followed by a constant infusion of 0.025 µg/min), and the control group, receiving insulin therapy. The blood glucose target range was 100 to 139 mg/dl. The primary outcome was the proportion of patients who spent at least 50% of the study period within the target range. The consumption of insulin (Cinsulin) and the time to start insulin (Tinsulin) were compared between the two groups.

Results: In total, 53 and 51 patients were included and analyzed in the exenatide and control groups, respectively (age: 70 ± 9 vs. 68 ± 11 yr; diabetes mellitus: 12 [23%] vs. 10 [20%]). The primary outcome was observed in 38 (72%) patients in the exenatide group and in 41 (80%) patients in the control group (odds ratio [95% CI] = 0.85 [0.34 to 2.11]; P = 0.30). Cinsulin was significantly lower (60 [40 to 80] vs. 92 [63 to 121] U, P < 0.001), and Tinsulin was significantly longer (12 [7 to 16] vs. 7 [5 to 10] h, P = 0.02) in the exenatide group.

Conclusions: Exenatide alone at the dose used was not enough to achieve adequate blood glucose control in coronary artery bypass grafting patients, but it reduces overall consumption of insulin and increases the time to initiation of insulin.
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http://dx.doi.org/10.1097/ALN.0000000000001838DOI Listing
November 2017

Acute Mesenteric Ischemia Among Postcardiac Surgery Patients Presenting with Multiple Organ Failure.

Shock 2017 03;47(3):296-302

*Medical Intensive Care Unit, Besançon University Hospital, Besançon, France †Surgical Intensive Care Unit, Besançon University Hospital, Besançon, France ‡Cardiac Surgery Unit, Besançon University Hospital, Besançon, France §Radiology Unit, Besançon University Hospital, Besançon, France ¶Digestive Surgery Unit, Besançon University Hospital, Besançon, France ||Gastroenterology Unit, Besançon University Hospital, Besançon, France #Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Australia **EA 3920 and INSERM IFR 133, University of Franche Comté, Besançon, France.

Background: Acute mesenteric ischemia (AMI) is a rare but severe complication after cardiac surgery. However, AMI is likely to be more frequent in the subgroup of patients presenting with multiple organ failure after a cardiac surgery. The primary objective of this study was to identify AMI risk factors among patients requiring intensive care unit (ICU) admission after cardiac surgery.

Methods: Retrospective observational study of all the patients requiring admission to two ICUs in a large university hospital after a cardiac surgery procedure. AMI confirmation was based on abdominal computed tomography scan, digestive endoscopy, laparotomy, or postmortem examination. Univariate and multivariate analyses were done to compare pre- and in-ICU characteristics between patients with or without AMI.

Results: Between 2007 and 2013, a cardiac surgery was performed in 4,948 patients, of whom 320 patients (6%) required ICU admission for multiple organ failure. AMI was confirmed in 10% of the patients admitted to the ICU for multiple organ failure (33/320). The prognosis of these patients was extremely poor with 28- and 90-day mortality rates of 64% and 83%, respectively. Nonocclusive mesenteric ischemia (NOMI) was the main mechanism involved in 83% of the patients. Coronary artery bypass graft, need for blood transfusion during cardiopulmonary bypass, aspartate aminotransferase at least 100 UI/L, and Simplified Acute Physiology Score II at least 50 at ICU admission were independently associated with AMI. An AMI risk score based upon these four risk factors was able to identify three classes of risk: low risk (<1%), intermediate risk (9%), and high risk (29%).

Conclusion: AMI is a frequent condition among patients presenting with multiple organ failure after cardiac surgery, occurring in 10% of them. The prognosis of AMI is extremely poor. The main mechanism of AMI is NOMI, occurring in approximately 80% of patients. Further progress should be performed on prevention and earlier diagnosis.
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http://dx.doi.org/10.1097/SHK.0000000000000720DOI Listing
March 2017

Quality organization and risk in anaesthesia: the French perspective.

Curr Opin Anaesthesiol 2017 Apr;30(2):230-235

aAnesthesia, Intensive Care and Emergency Medicine, University Paris-Est Créteil School of Medicine, Créteil, France bDepartment of Anesthesiology and Intensive Care Medicine, University of Franche-Comte cSchool of Medicine, University Hospital of Besancon, Franche-Comte University, Besancon, France.

Purpose Of Review: Ensuring the quality and safety of anaesthesia in the face of budgetary restrictions and changing demographics is challenging. In France, the environment is regulated by the legislation, and it is often necessary to find solutions that seize opportunities to break with the traditional organization.

Recent Findings: Postoperative mortality remains excessively high. The move towards ambulatory care is being adequately integrated into all the stages of patient management in the context of a single therapeutic plan that is mutually agreed upon by all caregivers. The French National Health Authority, which provides certification for healthcare establishments, encourages this 'seamless' approach between private practice and the hospital setting, based on teamwork and interdisciplinary consultation. By daring to break with traditional organizational structures, and by taking account of human factors and staged strategies, it is possible to deliver appropriate care, with a level of quality and safety that meets users' demands.

Summary: The management of a patient undergoing surgery with anaesthesia is a seamless spectrum from the patient's home to the hospital and back to home. Decision-making must be multidisciplinary. Increased use of ambulatory care, breaks with traditional organizational structures, and efforts to reduce postoperative mortality represents opportunities to improve overall system performance. Demographic and economic constraints are potential threats to be identified.
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http://dx.doi.org/10.1097/ACO.0000000000000432DOI Listing
April 2017

Ultrasound-guided intermediate cervical block versus superficial cervical block for carotid artery endarterectomy: The randomized-controlled CERVECHO trial.

Anaesth Crit Care Pain Med 2017 Apr 29;36(2):91-95. Epub 2016 Jul 29.

Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besançon, University of Franche-Comté, 3, boulevard Alexander-Fleming, 25000 Besançon, France; EA 3920 and SFR-FED 4234, University of Franche-Comté, 3, boulevard Alexander-Fleming, 25000 Besançon, France. Electronic address:

Introduction: The value of ultrasound guidance for intermediate cervical blocks in patients undergoing carotid artery endarterectomy is poorly described. This study aimed at comparing the efficacy of ultrasound-guided intermediate cervical block to superficial cervical block for carotid artery endarterectomies.

Patients And Methods: We conducted a single-centre randomized-controlled study in a French University Hospital, from April 2011 to March 2012. The anaesthesia technique was randomly allocated to patients scheduled for carotid artery endarterectomy under regional anaesthesia (ropivacaine 4.75mg/mL): superficial cervical block in the Control group, and ultrasound-guided intermediate cervical block in the Echo group. The main outcome measure was the percentage of surgery performed without supplemental topical anaesthesia. The secondary outcomes were: rate of conversion to general anaesthesia, amount of supplemental topical lidocaine and block-related complications. P<0.05 was considered significant.

Results: Demographic data for the 86 patients included [mean (SD) age 73 (11) years] did not differ between groups. Surgery was performed without supplemental topical lidocaine in 23% and 7% of the patients in the Echo and Control groups, respectively (P=0.068). Conversion to general anaesthesia for inadequate analgesia was needed in 0 and 2 patients in the Echo and Control groups, respectively. The mean dose of topical lidocaine was not different between groups. No complication directly related to a cervical block was observed.

Conclusions: Ultrasound-guided intermediate cervical plexus block and superficial cervical blocks performed for carotid artery surgery seems to provide similar results, but this study was probably underpowered to detect any difference.

Trial Registration: European Union Drug Regulating Authorities Clinical Trials (Eudra-CT) registration number: 2010-A 01490-39.
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http://dx.doi.org/10.1016/j.accpm.2016.03.007DOI Listing
April 2017

Propofol-remifentanil anesthesia for upper airway endoscopy in spontaneous breathing patients: the ENDOTANIL Randomized Trial.

Minerva Anestesiol 2016 11 31;82(11):1138-1148. Epub 2016 Aug 31.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, University of Franche-Comte, Besancon, France -

Background: The ENDOTANIL Trial aimed at comparing an association of target-controlled infusion (TCI) of remifentanil and propofol to TCI of propofol alone on the clinical conditions during pan endoscopy for assessment of the upper airway (pan endoscopy) performed under tubeless general anesthesia.

Methods: This double-blind, single center, parallel, randomized, placebo-controlled trial was conducted in a French tertiary level of care, from June 2009 to February 2013. Patients scheduled for elective pan endoscopy were anesthetized using propofol TCI combined to either remifentanil TCI (effect-site concentration=1.5 ng.mL-1; remifentanil group) or placebo (control group). The main outcome measure was the percentage of clinically acceptable conditions for pan endoscopy, using a 5-criteria score (ease of laryngoscopy, position and movements of the vocal cords, cough and movements of the limbs to stimulation). The secondary outcomes were hemodynamic and respiratory safety.

Results: In this study 218 patients (mean±SD age 60 [10] yrs) were included. Clinically acceptable conditions were observed in 68% and 64% of the patients included in Remifentanil and Control group, respectively (P=0.39). None of the 5 parameters of the pan endoscopy score was significantly different between the 2 groups. Hemodynamic alterations were significantly lower in the Remifentanil as compared to the control group. Incidence of hypoxemia or need for rescue mechanical ventilation did not significantly differ between the 2 groups.

Conclusions: The adjunction of remifentanil to propofol TCI, at a dose that maintain spontaneous breathing, did not improve the conditions for pan endoscopy, but attenuates the hemodynamic response induced by upper airway stimulation.
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November 2016

Surgical antibiotic prophylaxis compliance in a university hospital.

Anaesth Crit Care Pain Med 2015 Oct 15;34(5):289-94. Epub 2015 Sep 15.

UMR 6249 chrono-environnement, service d'hygiène hospitalière, centre hospitalier régional universitaire, 3, boulevard Fleming, 25000 Besançon, France.

Objective: To assess surgical antibiotic prophylaxis (SAP) practices in a university hospital in order to identify risk factors associated with non-compliance.

Study Design: Retrospective monocentric study conducted over a 4-month period.

Patients And Methods: Data were collected from the software used in the operating theatre. Practice non-compliance was evaluated in comparison with the 2010 version of the French national recommendations. We only took in account the interventions identified as priority surveillance interventions according to the surgical site infections national surveillance. The risk factors associated with SAP non-compliance were identified with a multivariate statistical analysis.

Results: We evaluated 1312 SAPs. Among the 1298 indicated SAPs, 44.4% were not compliant. The most frequent inappropriate criterion was the timing of injection (34.8% non-compliance), which was, in the majority of cases, too close to the time of incision. Other inappropriate criteria were identified: antibiotic choice for patients allergic to β-lactams (inappropriate among 45% of allergic patients), and antibiotic dosing for obese patients (96% of non-compliance). Obesity (OR=84.32), allergy to β-lactams (OR=17.11) and certain types of surgery (digestive, OR=4.56; gynaecological and obstetrical, OR=7.10; urological, OR=3.95) were independently associated with the non-compliance of SAP practices.

Conclusion: Improvement measures that target the timing of injection, obese or allergic patients are necessary.
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http://dx.doi.org/10.1016/j.accpm.2015.04.004DOI Listing
October 2015

Urapidil versus nicardipine in preeclamptic toxaemia: A randomised feasibility study.

Eur J Anaesthesiol 2015 Nov;32(11):822-3

From the Department of Anaesthesia and Critical Care, Hôpital de Hautepierre, Hôpitaux Universitaires, Strasbourg, Fédération de Médecine Translationnelle, FMTS, University of Strasbourg and EA3072 Hôpitaux Universitaires de Strasbourg (PD, VC, JP); Obstetric Anaesthesia, St James's University Hospital, Leeds, UK (LG); and Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besancon, EA 3920 and SFR-FED 4234 INSERM, France (SE).

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http://dx.doi.org/10.1097/EJA.0000000000000303DOI Listing
November 2015

Outcomes associated with routine systemic antifungal therapy in critically ill patients with Candida colonization.

Intensive Care Med 2015 Jun 18;41(6):1077-88. Epub 2015 Apr 18.

Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besancon, 25000, Besancon, France.

Purpose: To assess the evolution of patient deep colonization by Candida spp. in a surgical ICU over an 8-year period.

Methods: This retrospective, observational study included all patients hospitalized for more than 2 days in a surgical and trauma ICU of a university hospital, from 2005 to 2012. Mycological samples were monitored weekly from five sites (oropharyngeal, rectal, gastric, tracheal and urinary). Preemptive fluconazole therapy was started in patients highly colonized with Candida albicans. The evolution in Candida spp. involved in the deep colonization sites distribution over the study period (main outcome measure, trend chi-square and time-series analysis), antifungal consumption, ICU-acquired candidemia and mortality were determined.

Results: Among the 3029 patients with ICU stay >48 h, 2651 had at least one set of mycological sampling. Thirty percent of the 31,171 samples were positive to Candida spp. Caspofungin consumption increased over the years, whereas fluconazole consumption decreased. No trend in C. albicans colonization was observed, after adjusting on colonization risk-factors. A significant increase of acquired C. glabrata colonization was observed, whereas the clearing of C. parapsilosis colonization significantly decreased. No significant shift of colonization to other Candida spp. and mortality was observed.

Conclusions: Preemptive strategy of antifungal drug prescriptions in highly colonized ICU patients induced an increase in C. glabrata colonization without significant shift of colonization to other Candida spp. in surgical ICU patients. However, the potential detrimental impact of fluconazole on Candida ecology in ICU and/or on Candida susceptibility to antifungal drugs should be considered, and deserves further studies.
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http://dx.doi.org/10.1007/s00134-015-3791-4DOI Listing
June 2015

Ultrasound guidance of needle tip position for femoral nerve blockade: an observational study.

Eur J Anaesthesiol 2014 Jan;31(1):23-9

From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Besancon (BF, J-LC, AB, YH, FB, ES), EA 3920 and SFR-FED 4234 INSERM (AB, LT, ES), Department of Anatomy, University Hospital of Besancon, University of Franche Comte, Besancon (LT) and Albert Schweitzer Hospital, Colmar, France (DJ).

Background: The femoral nerve lies in the ilio-fascial space in a groove formed by the iliac and psoas muscles (GIPM) posteriorly, and overlaid by the iliac fascia. Recommendations for needle insertion for femoral blockade using ultrasound imaging are to insert the needle tip behind the iliac fascia at the lateral side of the femoral nerve, but this part of the nerve is poorly visualised in some patients. A more accurate location of the lateral part of the femoral nerve might be achieved by identifying the GIPM and its lateral segment.

Objectives: The objectives of this study are to determine the frequency of ultrasound visibility of the lateral part of the femoral nerve and GIPM, and to note the motor response to electrostimulation of the nerve and the spread of local anaesthetic when positioning the needle tip at the lateral segment of the GIPM.

Design: A prospective observational (case series) study.

Setting: Department of Anaesthesiology of a University Hospital.

Patients: Inpatients undergoing hip or knee surgery scheduled to have femoral nerve blockade were eligible to participate.

Interventions: The ultrasound probe was positioned in the inguinal region, and direct ultrasound identification of the femoral nerve, lying on the GIPM behind the iliac fascia, was obtained. A stimulating needle, inserted in-plane and advanced lateral to medial was directed towards the femoral nerve until it made contact with the target structure defined as the lateral segment of the GIPM.

Main Outcome Measure: Ultrasound identification of the lateral part of the femoral nerve and GIPM.

Results: An image compatible with the lateral part of the femoral nerve was observed in 91 out of 100 patients. In the remaining nine patients, when the lateral part of the femoral nerve was not seen, GIPM could be visualised in five (55%) patients. The iliac fascia and GIPM were clearly visualised in 68 and 85 patients respectively. In 85 cases when the needle tip was placed at the lateral segment of GIPM, a quadriceps femoris muscle motor response was obtained, and the distribution of the anaesthetic solution was observed behind the iliac fascia in all patients. In two patients, only the iliac fascia was identified, and in the two patients, none of these structures was correctly visualised.

Conclusion: The GIPM was seen in the majority undergoing ultrasound-guided femoral nerve blockade, even when the lateral part of the femoral nerve was not visualised. Using the lateral segment of GIPM as a target for needle tip location in an in-plane lateral to medial approach of the femoral nerve deserves further investigation.
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http://dx.doi.org/10.1097/01.EJA.0000435016.83813.aaDOI Listing
January 2014

Recovery from anesthesia after craniotomy for supratentorial tumors: comparison of propofol-remifentanil and sevoflurane-sufentanil (the PROMIFLUNIL trial).

J Neurosurg Anesthesiol 2014 Jan;26(1):37-44

*Department of Anesthesiology, Intensive care and Pain Management, Beaujon University Hospital, Clichy ‡Department d'Epidémiologie et Recherche Clinique, Paris ∥Department of Anesthesiology and Intensive Care, University Hospitals of Besançon, Besançon #Department of Anesthesiology, Intensive Care and Pain Management, Robert Debré University Hospital †Faculté de Médecine Denis DIDEROT (Paris VII), Paris ¶Faculté de Médecine de Besançon, Besançon **UMR INSERM U 676, Robert Debré University Hospital §INSERM, CIE 801, Paris, France.

Introduction: Rapid recovery after supratentorial tumors (STT) removal is important. Short-acting anesthetics, such as propofol and remifentanil might favor this objective. The aim of this study was to compare the recovery of 2 Bispectral index (BIS)-guided anesthesia protocols combining sevoflurane-sufentanil (SS) or propofol-remifentanil (PR) administered during craniotomy for STT.

Materials And Methods: After IRB approval and written consent, patients scheduled for surgical removal of STT were randomized to receive PR or SS. Anesthesia was adjusted to maintain BIS values between 45 and 55. The primary outcome was the time from discontinuation of anesthetics to extubation. Secondary endpoints were: time to respond to a simple order, and to achieve spontaneous ventilation, agitation score at emergence, postoperative Mini Mental State, postoperative Aldrete score, pain Visual Analogical Score, simplified sedation score, Glasgow Coma Scale, and surgical complications. Statistical analyses were performed using analysis of variance.

Results: Thirty-five and 31 were included in the SS and PR groups, respectively. Times to extubation was not different between the 2 groups (11.8±6.9 vs. 13.0±8.1 min in PR and SS groups, respectively, P=0.577). Although times to achieve an Aldrete score to 10, a Glasgow Coma Scale to 15, and a MMS to 30 significantly were lower in SS group, no significant difference was found when analyzing time course of these 3 factors over the first postoperative day. All other secondary endpoints were not different between the 2 groups.

Conclusion: During craniotomy for STT, we could not demonstrate a reduction in the time to extubation when comparing a BIS-guided anesthesia associating PR to a BIS-guided anesthesia associating SS (Clinicatrials.gov identifier: NCT00389883).
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http://dx.doi.org/10.1097/ANA.0b013e31829cc2d6DOI Listing
January 2014

Predictive factors of advanced interventional procedures in a multicentre severe postpartum haemorrhage study.

Intensive Care Med 2011 Nov 30;37(11):1816-25. Epub 2011 Jul 30.

Department of Anesthesiology and Critical Care Medicine, Mobile Care Unit, Lariboisière University Hospital, AP-HP, EA322, Paris Cedex 10, France.

Purpose: Severe postpartum haemorrhage (SPPH) is the leading cause of peripartum hysterectomy and maternal death. There are no easily measurable parameters that indicate the failure of medical therapy and the need for an advanced interventional procedure (AIP) to stop genital tract bleeding. The aim of the study was to define factors predictive of the need for an AIP in the management of emergent PPH.

Methods: The study included two phases: (1) an initial retrospective study of 257 consecutive patients with SPPH, allowing the determination of independent predictors of AIP, which were subsequently grouped in a predictive score, followed by (2) a multicentre study of 239 patients admitted during 2007, designed to validate the score. The main outcome measure was the need for an AIP, defined as uterine artery embolization, intraabdominal packing, arterial ligation or hysterectomy.

Results: Abnormalities of placental implantation, prothrombin time <50% (or an International Normalized Ratio >1.64), fibrinogen <2 g/l, troponin detectable, and heart rate >115 bpm were independently predictive of the need for an AIP. The SPPH score included each of the five predictive factors with a value of 0 or 1. The greater the SPPH score, the greater the percentage of patients needing an AIP (11% for SPPH 0, to 75% for SPPH ≥2). The AUC of the ROC curve of the SPPH score was 0.80.

Conclusions: We identified five independent predictors of the need for an AIP in patients with SPPH and persistent bleeding. Using these predictors in a single score could be a reliable screening tool in patients at risk of persistent genital tract bleeding and needing an AIP.
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http://dx.doi.org/10.1007/s00134-011-2315-0DOI Listing
November 2011

Protective effect of intra-peritoneal epinephrine on postoperative renal function after cisplatin-based intra-peritoneal intra-operative chemotherapy.

Eur J Obstet Gynecol Reprod Biol 2011 Jun 8;156(2):199-203. Epub 2011 Feb 8.

Univ Franche-Comte, F-25000 Besancon, France.

Objectives: Intra-operative cisplatin-based intra-peritoneal chemotherapy (IPC) may alter renal function in patients with advanced ovarian cancer. The aim of this study was to describe postoperative alteration of renal function after cisplatin-based IPC and to identify risk factors for moderate to severe acute renal failure.

Study Design: This prospective observational study was carried out on 77 consecutive patients who underwent cisplatin-based IPC procedures, with (n=23) or without (n=54) intra-peritoneal epinephrine, for advanced ovarian cancer. Postoperative renal function was assessed using serial serum creatinine measurements and was based on serum creatinine changes from pre-operative values, according to the risk, injury, failure, loss, end-stage kidney disease (RIFLE) classification. Patients were divided into two groups according to postoperative renal function: patients with renal injury or failure (IF group) or patients with no renal alteration or renal risk (NR group). Clinical variables were compared between the IF and NR groups using univariate and multivariate analysis.

Results: Postoperative acute change in renal function was observed in 34 (44.2%) patients (unimodal distribution), among whom 23 patients (29.8%) constituted the IF group. In univariate analysis, the absence of epinephrine in the IPC bath, a higher duration of severe hypotension, a lower postoperative blood protein level, and a lower volume of intra-operative diuresis were significantly associated with the occurrence of renal injury or failure. In multivariate analysis, the absence of epinephrine was the only factor associated with the occurrence of moderate to severe acute renal failure (odds ratio [95% confidence interval]=4.49 [1.36-14.80]).

Conclusions: Transient acute renal dysfunction after cisplatin-based IPC associated with cytoreductive surgery is frequent and intra-peritoneal epinephrine plays a protective role.
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http://dx.doi.org/10.1016/j.ejogrb.2011.01.006DOI Listing
June 2011
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