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Plaud B, Baillard C, Bourgain JL, Bouroche G, Desplanque L, Devys JM, Fletcher D, Fuchs-Buder T, Lebuffe G, Meistelman C, Motamed C, Raft J, Servin F, Sirieix D, Slim K, Velly L, Verdonk F, Debaene B. Guidelines on muscle relaxants and reversal in anaesthesia. Anaesth Crit Care Pain Med 2020; 39:125-142. [PMID: 31926308 DOI: 10.1016/j.accpm.2020.01.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.
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Affiliation(s)
- Benoît Plaud
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Christophe Baillard
- Université de Paris, Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Cochin-Port Royal, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Jean-Louis Bourgain
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Gaëlle Bouroche
- Centre Léon-Bérard, service d'anesthésie, 28, promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France
| | - Laetitia Desplanque
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Jean-Michel Devys
- Fondation ophtalmologique Adolphe-de-Rothschild, service d'anesthésie et de réanimation, 29, rue Manin, 75019 Paris, France
| | - Dominique Fletcher
- Université de Versailles-Saint-Quentin-en-Yvelines, Assistance publique-Hôpitaux de Paris, hôpital Ambroise-Paré, service d'anesthésie, 9, avenue Charles-de-Gaulle, 92100 Boulogne-Billancourt, France
| | - Thomas Fuchs-Buder
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Gilles Lebuffe
- Université de Lille, hôpital Huriez, service d'anesthésie et de réanimation, rue Michel-Polonovski, 59037 Lille, France
| | - Claude Meistelman
- Université de Lorraine, CHU de Brabois, service d'anesthésie et de réanimation, rue du Morvan, 54511 Vandœuvre-lès-Nancy, France
| | - Cyrus Motamed
- Institut Gustave-Roussy, service d'anesthésie, 114, rue Édouard-Vaillant, 94800 Villejuif, France
| | - Julien Raft
- Institut de cancérologie de Lorraine, service d'anesthésie, 6, avenue de Bourgogne, 54519 Vandœuvre-lès-Nancy, France
| | - Frédérique Servin
- Assistance publique-Hôpitaux de Paris, service d'anesthésie et de réanimation, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75877 Paris cedex, France
| | - Didier Sirieix
- Groupe polyclinique Marzet-Navarre, service d'anesthésie, 40, boulevard d'Alsace-Lorraine, 64000 Pau, France
| | - Karem Slim
- Université d'Auvergne, service de chirurgie digestive et hépatobiliaire, hôpital d'Estaing, 1, rue Lucie-Aubrac, 63100 Clermont-Ferrand, France
| | - Lionel Velly
- Université Aix-Marseille, hôpital de la Timone adultes, service d'anesthésie et de réanimation, 264, rue Saint-Pierre, 13385 Marseille cedex 05, France
| | - Franck Verdonk
- Sorbonne université, hôpital Saint-Antoine, 84, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Bertrand Debaene
- Université de Poitiers, service d'anesthésie et de réanimation, CHU de Poitiers, BP 577, 86021 Poitiers cedex, France
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Mongardon N, Bouglé A, Sola C, Bouroche G, Verdonk F, Le Gall A, Bataille A, Beylacq L, Bourgeois E, Charbit J, Guerci P, Chousterman BG. Publication outcome of abstracts presented at an Anesthesiology and Critical Care Medicine meeting: Does being a junior presenter matter? J Clin Anesth 2019; 60:49-50. [PMID: 31445178 DOI: 10.1016/j.jclinane.2019.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/29/2019] [Accepted: 08/12/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Nicolas Mongardon
- Service d'Anesthésie-Réanimation Chirurgicale, CHU Henri Mondor, Créteil, France.
| | - Adrien Bouglé
- Département d'Anesthésie et de Réanimation, Hôpital Universitaire La Pitié - Salpêtrière, Paris, France
| | - Chrystelle Sola
- Service d'Anesthésie-Réanimation Pédiatrique, CHU Lapeyronie, Montpellier, France
| | - Gaëlle Bouroche
- Service d'Anesthésie-Réanimation, Centre de Lutte contre le Cancer Léon Bérard, Lyon, France
| | - Franck Verdonk
- Service d'Anesthésie-Réanimation, Hôpital Saint-Antoine, Paris, France
| | - Arthur Le Gall
- Département d'Anesthésie-Réanimation, Hôpital Lariboisière, DMU Parabol, AP-HP, Paris, France
| | - Aurélien Bataille
- Département d'Anesthésie-Réanimation, Hôpital Lariboisière, DMU Parabol, AP-HP, Paris, France
| | - Lucie Beylacq
- Service d'Anesthésie-Réanimation 3, CHU de Bordeaux, Bordeaux, France
| | - Eric Bourgeois
- Service d'Anesthésie, Centre Hospitalier Privé Saint-Grégoire, Saint-Grégoire, France
| | - Jonathan Charbit
- Service d'Anesthésie-Réanimation, CHU Lapeyronie, Montpellier, France
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Langeron O, Bourgain JL, Francon D, Amour J, Baillard C, Bouroche G, Chollet Rivier M, Lenfant F, Plaud B, Schoettker P, Fletcher D, Velly L, Nouette-Gaulain K. Difficult intubation and extubation in adult anaesthesia. Anaesth Crit Care Pain Med 2018; 37:639-651. [DOI: 10.1016/j.accpm.2018.03.013] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 12/17/2022]
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Bouroche G, Motamed C, de Guibert J, Hartl D, Bourgain J. Rescue transtracheal jet ventilation during difficult intubation in patients with upper airway cancer. Anaesth Crit Care Pain Med 2018; 37:539-544. [DOI: 10.1016/j.accpm.2017.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/24/2017] [Accepted: 10/14/2017] [Indexed: 01/08/2023]
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Duceau B, Baubillier M, Bouroche G, Albi-Feldzer A, Jayr C. Pupillary Reflex for Evaluation of Thoracic Paravertebral Block: A Prospective Observational Feasibility Study. Anesth Analg 2017; 125:1342-1347. [PMID: 28489642 DOI: 10.1213/ane.0000000000002003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although thoracic paravertebral block (TPVB) is recommended in major breast surgery, there is no gold standard to assess the success of TPVB. Pupillary dilation reflex (PDR) is the variation of the pupillary diameter after a noxious stimulus. The objective was to evaluate the feasibility of recording the PDR to assess analgesia in an anesthetized thoracic dermatome after TPVB. METHODS This prospective, observational, single-center study included 32 patients requiring breast surgery under general anesthesia and TPVB. TPVB was performed before surgery under ultrasound guidance with 20 mL of 0.75% ropivacaine. At the end of the surgery, remifentanil was stopped and the PDR was recorded after a 5-second tetanic stimulation (60 mA, 100 Hz) applied to the anterior chest wall. The PDR was defined as the maximal increase in pupil diameter after a standardized noxious stimulus, expressed as a percentage of the initial pupil diameter. The PDR was recorded twice in the same eye for each patient after a stimulus on both the TPVB and the control sides. Postoperative pain scores were recorded in a postanesthesia care unit. The primary outcome was the difference between the PDR on the TPVB and the control sides. RESULTS The median (interquartile range) PDR was 9% (4%-13%) on the TPVB side and 41% (27%-66%) on the control side. There was a significant difference in the PDR between the TPVB and the control sides with a Hodges-Lehmann estimate of absolute difference of 37% points (95% confidence interval, 25-52, P < .001). Median postoperative pain scores (interquartile range) in the postanesthesia care unit were 1 (0-3) at rest and 1 (0-3) during mobilization, respectively. There was a linear correlation between maximal postoperative pain scores and the PDR on the TPVB side with a Pearson's correlation coefficient r = 0.40 (95% confidence interval, 0.06-0.66, P = .02). No correlation was found between the number of blocked dermatomes and maximal postoperative pain scores (P = .06) or between the number of blocked dermatomes and the PDR on the TPVB side (P = .15). CONCLUSIONS This proof-of-concept trial suggests that the effect of TPVB could be monitored by measuring the PDR after anterior chest wall stimulation in the dermatome of interest.
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Affiliation(s)
- Baptiste Duceau
- From the *Institut Curie, Hôpital René Huguenin, Saint-Cloud, France; and †Institut Gustave Roussy, Villejuif, France
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Philippart F, Bouroche G, Timsit JF, Garrouste-Orgeas M, Azoulay E, Darmon M, Adrie C, Allaouchiche B, Ara-Somohano C, Ruckly S, Dumenil AS, Souweine B, Goldgran-Toledano D, Bouadma L, Misset B. Decreased Risk of Ventilator-Associated Pneumonia in Sepsis Due to Intra-Abdominal Infection. PLoS One 2015; 10:e0137262. [PMID: 26339904 PMCID: PMC4560443 DOI: 10.1371/journal.pone.0137262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 08/13/2015] [Indexed: 12/26/2022] Open
Abstract
RATIONALE Experimental studies suggest that intra-abdominal infection (IAI) induces biological alterations that may affect the risk of lung infection. OBJECTIVES To investigate the potential effect of IAI at ICU admission on the subsequent occurrence of ventilator-associated pneumonia (VAP). METHODS We used data entered into the French prospective multicenter Outcomerea database in 1997-2011. Consecutive patients who had severe sepsis and/or septic shock at ICU admission and required mechanical ventilation for more than 3 days were included. Patients with acute pancreatitis were not included. MEASUREMENTS AND MAIN RESULTS Of 2623 database patients meeting the inclusion criteria, 290 (11.1%) had IAI and 2333 (88.9%) had other infections. The IAI group had fewer patients with VAP (56 [19.3%] vs. 806 [34.5%], P<0.01) and longer time to VAP (5.0 vs.10.5 days; P<0.01). After adjustment on independent risk factors for VAP and previous antimicrobial use, IAI was associated with a decreased risk of VAP (hazard ratio, 0.62; 95% confidence interval, 0.46-0.83; P<0.0017). The pathogens responsible for VAP were not different between the groups with and without IAI (Pseudomonas aeruginosa, 345 [42.8%] and 24 [42.8%]; Enterobacteriaceae, 264 [32.8%] and 19 [34.0%]; and Staphylococcus aureus, 215 [26.7%] and 17 [30.4%], respectively). Crude ICU mortality was not different between the groups with and without IAI (81 [27.9%] and 747 [32.0%], P = 0.16). CONCLUSIONS In our observational study of mechanically ventilated ICU patients with severe sepsis and/or septic shock, VAP occurred less often and later in the group with IAIs compared to the group with infections at other sites.
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MESH Headings
- Aged
- Bacterial Infections/complications
- Bacterial Infections/microbiology
- Bacterial Infections/mortality
- Bacterial Infections/pathology
- Databases, Factual
- Enterobacteriaceae/growth & development
- Female
- Humans
- Intensive Care Units
- Intraabdominal Infections/complications
- Intraabdominal Infections/microbiology
- Intraabdominal Infections/mortality
- Intraabdominal Infections/pathology
- Length of Stay
- Male
- Middle Aged
- Pneumonia, Ventilator-Associated/complications
- Pneumonia, Ventilator-Associated/microbiology
- Pneumonia, Ventilator-Associated/mortality
- Pneumonia, Ventilator-Associated/pathology
- Prospective Studies
- Pseudomonas aeruginosa/growth & development
- Respiration, Artificial
- Risk Factors
- Shock, Septic/complications
- Shock, Septic/microbiology
- Shock, Septic/mortality
- Shock, Septic/pathology
- Staphylococcus aureus/growth & development
- Survival Analysis
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Affiliation(s)
- François Philippart
- Medical-Surgical ICU, Groupe Hospitalier Paris Saint Joseph, Paris, France
- * E-mail:
| | - Gaëlle Bouroche
- Department of Anesthesia and Intensive Care, Gustave Roussy Institute, Villejuif, France
| | - Jean-François Timsit
- Université Grenoble 1, U823, Albert Bonniot Institute, La Tronche, France
- Medical ICU, Groupe hospitalier Bichat-Claude Bernard, Paris, France
| | - Maité Garrouste-Orgeas
- Medical-Surgical ICU, Groupe Hospitalier Paris Saint Joseph, Paris, France
- Université Grenoble 1, U823, Albert Bonniot Institute, La Tronche, France
| | - Elie Azoulay
- Medical ICU, Saint Louis Teaching Hospital, Paris, France
- Université Paris VII—Denis Diderot, Paris, France
| | | | | | - Bernard Allaouchiche
- Surgical ICU, Edouart Herriot Hospital, Lyon, France
- Université Lyon I—Claude Bernard, Lyon, France
| | - Claire Ara-Somohano
- Université Grenoble 1, U823, Albert Bonniot Institute, La Tronche, France
- Medical ICU, Albert Michallon Teaching Hospital, Grenoble, France
| | - Stéphane Ruckly
- Université Grenoble 1, U823, Albert Bonniot Institute, La Tronche, France
| | | | - Bertrand Souweine
- Medical ICU, Gabriel Montpied University Hospital, Clermont-Ferrand, France
| | | | - Lila Bouadma
- Université Paris VII—Denis Diderot, Paris, France
- Medical-Surgical ICU, Gonesse Hospital, Gonesse, France
| | - Benoît Misset
- Medical-Surgical ICU, Groupe Hospitalier Paris Saint Joseph, Paris, France
- Université Paris Descartes, Paris, France
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Bouroche G, Bourgain JL. Preoxygenation and general anesthesia: a review. Minerva Anestesiol 2015; 81:910-920. [PMID: 26044934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Because intubation can potentially become a lengthy procedure, the risk of arterial oxygen (O2) desaturation during intubation must be considered. Preoxygenation should be routine, as oxygen reserves are not always sufficient to cover the duration of intubation. Three minutes of spontaneous breathing at FiO2=1 allows denitrogenation with FAO2 close to 95% in patients with normal lung function. Tolerable apnea time, defined as the delay until the SpO2 reaches 90%, can be extended up to almost 10 minutes after 3 minutes of classic preoxygenation. Eight deep breaths within 60 seconds allow a comparable increase in O2 reserves. For effectiveness, the equipment must be adapted and tightly fitted. Inadequate preoxygenation (FeO2 <90% after three minutes tidal volume breathing) is frequently observed. Predictive risk factors for inadequate pre-oxygenation share overlap with criteria predictive of difficult mask ventilation. In cases of respiratory failure, oxygenation can be improved by positive end expiration pressure or by pressure support. In morbidly obese patients, preoxygenation is enhanced in a seated position (25°) and by use of positive pressure ventilation. O2 can also be administered during the intubation procedure; techniques include pharyngeal O2, special oxygen mask, or even pressure support ventilation for patients with spontaneous ventilation or positive pressure ventilation to the facial mask for apneic patients. Clinicians (especially anesthesiologists trained in ENT and traumatology) must be prepared to handle life-threatening emergency situations by alternate methods including trans-tracheal ventilation. The availability of equipment and training are two essential components of adequate preparation.
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Affiliation(s)
- G Bouroche
- Service d'Anesthésie Gustave Roussy, Villejuif, France -
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Chousterman BG, Bouroche G, Verdonk F, Chhor V. [Evaluation of residency training and needs of fellowships by anaesthesia and intensive care residents of Île-de-France]. ACTA ACUST UNITED AC 2012; 31:739-40. [PMID: 22840928 DOI: 10.1016/j.annfar.2012.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 05/31/2012] [Indexed: 11/29/2022]
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