Orthotopic liver transplantation can be associated with haemorrhage, particularly in patients with severe liver dysfunction. We assessed the value of rotation thromboelastometry (ROTEM®) to monitor ...coagulation in the operating theatre, its correlation with routine laboratory findings, and its ability to guide platelet (Plt) and fibrinogen (Fg) transfusion.
Twenty-three patients were included in this prospective observational study. Laboratory tests and ROTEM® tests (EXTEM, INTEM, FIBTEM, and APTEM) were performed six times during the procedure. Correlations between laboratory findings and ROTEM® parameters were sought. Thresholds for ROTEM® parameters were determined with receiver-operating characteristic (ROC) curve analysis according to Plt count and Fg levels.
Clot amplitude at 10 min (A10) of EXTEM was well correlated with Plt count and Fg levels (R2=0.46 and 0.52, respectively, P<0.0001). FIBTEM A10 was correlated with Fg (R2=0.55, P<0.0001). ROC analysis showed that EXTEM A10 with a threshold of 29 mm predicted thrombocytopenia with a sensitivity of 79% and a specificity of 60%, and a threshold of 26 mm predicted hypofibrinogenaemia with a sensitivity of 83% and a specificity of 75%.
ROTEM® is useful for the global assessment of coagulation in the operating theatre. EXTEM was the most informative for assessing the whole coagulation process and A10 showed value in guiding Plt and Fg transfusion.
Variceal upper gastrointestinal bleeding is a dreadful complication of portal hypertension with a significant morbidity and mortality. Different prognostic scores can be used. However, in the local ...context of Madagascar, the completion of paraclinical investigations can be delayed by the limited financial means of patients. Hence, determining clinical mortality risk factors of variceal upper gastrointestinal bleeding could be interesting. The aim of the study was to evaluate the clinical mortality risk factors of variceal gastrointestinal bleeding (VUGIB).
An observational, cohort retrospective study was conducted over an 8-year period (2010–2017), at the surgical intensive care unit of the J.R. Andrianavalona University Hospital, Antananarivo, in patients admitted for VUGIB confirmed by upper gastrointestinal endoscopy and whose clinical examination was performed at admission. The primary endpoint was intensive care unit (ICU) mortality. Univariate analysis and multivariate logistic regression analysis were performed to identify risk factors for ICU mortality, with OR defining odds ratio. A p value <0.05 was considered significant.
1920 patients were admitted for gastrointestinal bleeding of any digestive causes; the source of bleeding was variceal in 269 patients (14%). The predominantly male population (sex ratio = 2.5), aged 47.1 ± 13.7 years was mostly American Society of Anesthesiologists (ASA) 1 classification (58.4%). In 56.5% of patients, the gastrointestinal bleeding had not occurred before. The mortality rate was 16.0%. Three major clinical factors of mortality were identified: previous endoscopic band variceal ligation (OR = 12.57 2.18–72.58, p = 0.005), tachycardia >120 bpm (OR = 2.91 1.04–8.14, p = 0.041), and ascites (OR = 3.80 1.85–7.81, p < 0.001).
Upper gastrointestinal bleeding may be life-threatening. The mortality scores are certainly useful; however, the identification of clinical factors is interesting in countries like Madagascar, pending the results of paraclinical investigations.
Professional practice evaluation of anaesthesiologist for high cardiac-risk patient cares in non-cardiac surgery, and assess disparities between results and recommendations.
Since June to September ...2011, a self-questionnaire was sent to 5000 anesthesiologist. They were considered to be representative of national anesthesiology practitioner. Different items investigated concerned: demography, preoperative cardiac-risk assessment, modalities of specialized cardiologic advice, per- and postoperative care, and finally knowledge of current recommendations.
We collected 1255 questionnaire, that is to say 25% of answers. Men were 73%, 38% were employed by public hospital; 70% worked in a shared operating theatre with a general activity. With regards to preoperative assessment, 85% of anaesthetists referred high cardiac-risk patient to a cardiologist. In only 16% of answer, Lee's score appeared in anaesthesia file to assess perioperative cardiac-risk. Only 61% considered the six necessary items to optimal estimate of cardiac-risk. On the other hand, 91% measured routinely the exercise capacities by interrogation. The most frequently doing exam (49% of anaesthetist) was an electrocardiogram in elderly patient. In 96% of case, beta-blockers were given in premedication if they were usually thought. Clopidogrel was stopped by 62% of anesthetist before surgery. In this case, 38% used another medication to take over from this one. Only 7% considered revascularization in coronary patient who were effectively treated. POISE study was know by 40% of practitioner, and 18% estimated that they have changed their practice. Preoperatively, 21% organized multidisciplinary approach for high-risk patient. During surgery, 63% monitored the ST-segment. In postoperative period for cardiac-risk patient, only 11% prescribed systematically an ECG, a troponin dosage, a postoperative monitoring of ST-segment, a cardiologic advice. In case of moderate troponin elevation, they were 70% to realize at least an ECG and/or an echocardiography.
This study highlights some difference between current recommendation concerning assessment of cardiac-risk patient in non-cardiac surgery and daily practice of anesthetist, justifying regular update of this one.
To assess the current use of sedation and analgesia in a large sample of French intensive care units (ICUs) and to define structural characteristics of the units that use a written procedure.
...Self-reported survey.
Three hundred and sixty French ICUs were presented the questionnaire in September 2007.
Surveys were received from 228 (60.6%) ICUs. Midazolam was used in more than 50% of the patients in 79.2% of the ICUs and propofol in 22.2% of the ICUs. Sufentanil was the most frequently used morphinic. A sedation-scale was used in 68.8% of the units (80.3% Ramsay score). Sedation was assessed at least every 4hours in 61% of ICUs. A pain-scale was used in 88.9% of the ICUs, but only 12.5% in the non-communicant patients. A written procedure was used in 29.4% of the units only. In multivariate analysis, use in the ICU of a written procedure for the early management of patients with septic shock and/or intensive insulin therapy was the single variable significantly associated with presence of a written procedure for sedation and analgesia (respectively OR 4.37; p<0.0001 and OR 5.64; p=0.032).
Although more than two-third of the responding ICUs reported the use of sedation-and-pain-scales, frequency of assessment was low, and objective assessment of pain in the non-communicating patients was extremely uncommon. Similarly, the use of written procedure was low. The use of sedation-analgesia written procedure in an ICU seems strongly influenced by a more global involvement of the ICU in the protocolisation of complex care. These findings support the reinforcement of educational programs.
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