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Objetivo. La tromboelastometría evalúa la coagulación analizando la viscoelasticidad de una muestra de sangre. Nuestro objetivo principal fue evaluar los resultados de su uso como guía de administración de hemoderivados en cirugía cardiaca y, secundariamente, las complicaciones postoperatorias y el tiempo de hospitalización en UCI. Material y método. Estudio analítico, de intervención, cuasiexperimental, comparativo, no aleatorizado, prospectivo, con un grupo control retrospectivo. Se incluyeron 80 pacientes reintervenidos de cualquier cirugía cardiaca, o cirugías por endocarditis o del arco aórtico. En 31 pacientes los hemoderivados intraoperatorios se administraron según pautas clínicas tradicionales (grupo A). Los 49 pacientes restantes recibieron hemoderivados siguiendo algoritmos basados en el análisis tromboelastométrico (grupo B). El objetivo principal fue la administración de hemoderivados y los objetivos secundarios fueron: estancia en UCI y complicaciones postoperatorias. Resultados. Hubo una importante disminución en la administración de plasma fresco congelado en el grupo B respecto al A (p<0,001), así como una disminución en la transfusión intraoperatoria de sangre: 3,9 concentrados de hematíes de media por paciente en el grupo A frente a 2,67 en el grupo B (p=0,125). Se incrementó la administración de fibrinógeno, con una p<0,019. Se encontró una menor tasa de complicaciones respiratorias (p=0,019) en el grupo B y una reducción significativa de las estancias mayores de 7 días en el grupo B respecto al A (p=0,031). Conclusiones. La tromboelastometría condujo a una importante disminución en la utilización de plasma fresco congelado, contribuyendo muy probablemente al descenso en la incidencia de complicaciones respiratorias y en la menor estancia en UCI (AU)

Objective. Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay. Material and method. Analytical and comparative non-randomised quasi-experimental prospective study with a retrospective control group. The inclusion criteria for the 80 patients were: patients undergoing cardiac surgery who had had prior cardiac surgery, endocarditis surgery or aortic arch surgery. Thirty-one patients were treated following routine transfusion practice during surgery (group A). The other 49 patients were treated with thromboelastometrically guided transfusion algorithms (group B). The main objective was blood products transfused, and postoperative adverse events and ICU stay were the secondary objectives. Results. Statistical analysis showed lower transfusion rates of fresh-frozen plasma in group B compared to group A (P<.001), as well as red blood cell transfusion during surgery with an average transfusion rate of 3.9 units in group A in comparison to 2.67 units in group B (P=.125). Moreover, fibrinogen infusion was increased in group B compared to group A (P=.019). In addition, a lower rate of respiratory adverse events was found in group B (P=.019). There was a significant decrease in ICU stays over 7 days in group B compared to group A (P=.031). Conclusions. Using thromboelastometry guidance for blood management led to a meaningful reduction of fresh frozen plasma transfusion during surgery. This probably resulted in a reduction in respiratory adverse events after surgery and length of ICU stay in our patients (AU)

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OBJECTIVE: Thromboelastometry is a viscoelastometric method for haemostasis testing in a whole blood sample. The aim of this study was to assess the results of using thromboelastometry as guidance for blood management in cardiac surgery, postoperative adverse events and ICU stay. MATERIAL AND METHOD: Analytical and comparative non-randomised quasi-experimental prospective study with a retrospective control group. The inclusion criteria for the 80 patients were: patients undergoing cardiac surgery who had had prior cardiac surgery, endocarditis surgery or aortic arch surgery. Thirty-one patients were treated following routine transfusion practice during surgery (group A). The other 49 patients were treated with thromboelastometrically guided transfusion algorithms (group B). The main objective was blood products transfused, and postoperative adverse events and ICU stay were the secondary objectives. RESULTS: Statistical analysis showed lower transfusion rates of fresh-frozen plasma in group B compared to group A (P<.001), as well as red blood cell transfusion during surgery with an average transfusion rate of 3.9 units in group A in comparison to 2.67 units in group B (P=.125). Moreover, fibrinogen infusion was increased in group B compared to group A (P=.019). In addition, a lower rate of respiratory adverse events was found in group B (P=.019). There was a significant decrease in ICU stays over 7 days in group B compared to group A (P=.031). CONCLUSIONS: Using thromboelastometry guidance for blood management led to a meaningful reduction of fresh frozen plasma transfusion during surgery. This probably resulted in a reduction in respiratory adverse events after surgery and length of ICU stay in our patients.

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The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane.

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OBJECTIVE: The monitoring in the post-anaesthesia care unit (PACU) improves the safety, the comfort and the analgesia of patients. At present, studies suggest the possibility to bypass the PACU according to the principle of fast-tracking (FT). The aim of this study was to evaluate the feasibility and the safety of a simulated protocol of FT after a regional anaesthesia. PATIENTS AND METHODS: Seven hundred patients were prospectively included in this study over a period of 6 months. METHODS: The Withes' scoring system was used for determining when patients could be safely discharged from PACU. We added a variable concerning the monitoring of surgical site. A minimum score of 14 was required on arrival to the PACU to consider a FT. The success rate of blocks, the use of sedation or general anaesthesia were noted. Adverse events were recorded. RESULTS: The success rate of blocks was 93 %. The score was higher than 14 in 98 % of case on arrival to the PACU. Thirteen adverse events were reported before surgery and/or operating room. No adverse events were reported during the stay in the PACU. CONCLUSION: Regional anaesthesia seems to be an appropriate principle to fast-track the PACU. It could be a way to reduce health care costs, and can offer solution for the PACU congestion problem. In France, the fast-tracking is a marginal concept without any support regulatory. An evolution to such a practice could be considered.

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BACKGROUND: Because poor echogenicity of the needle remains a safety issue, we decided to analyze the learning process of the hydrolocalization technique (Hloc) performed to continuously identify needle-tip anatomical position during many ultrasound-guided regional anesthesia procedures. METHODS: Ten senior anesthesiologists naïve to the Hloc agreed to participate in the study. They were requested to perform 40 out-of-plane (OOP) approach ultrasound-guided axillary blocks (AB) each using the Hloc. The Hloc, which is a needle-tip localization principle, was performed by means of repetitive injections of a small amount of a local anesthetic solution (0.5-1 ml) under an ultrasound beam. Details of the learning process and skill acquisition of the Hloc were derived from the following parameters: the duration of block placement, a measure of the perceived difficulty of needle-tip visualization, a measure of block placement difficulty, and the amount of local anesthetics solution required for the technique. RESULTS: Four hundred ABs were performed. The success rate of an ultrasound-guided AB was 98%. The Hloc was successful in all patients. Skill acquisition over time of the Hloc was associated with a significant reduction of both the duration and the perceived difficulty of ABs placement. Apprenticeship data revealed that 20 blocks were required to successfully place AB within 5 min in most cases using the Hloc. CONCLUSION: The Hloc performed during the OOP approach of ultrasound-guided regional anesthesia is a simple technique with a relatively short learning process feasible for efficient placement of ABs.

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INTRODUCTION: Infection with human immunodeficiency virus (HIV) is associated with end-stage renal disease (ESRD). Although many teams initially were reluctant to offer kidney transplantation as a therapeutic option in HIV-positive patients with ESRD, new drug regimens introduced in the late 1990s have dramatically improved the life expectancy in these patients. OBJECTIVE: To report the results of the first 7 kidney transplantation procedures in HIV-positive patients at our institution. PATIENTS AND METHODS: Patients were selected to minimize the risks of HIV disease progression, opportunistic infections, and tumors. Protease-inhibitor therapies were suspended because of possible interaction with immunosuppression drugs. The induction regimen did not include lymphocyte-depleting drugs. After undergoing transplantation, patients were monitored by the transplantation and infectious disease teams. RESULTS: To date, all patients are alive with functioning grafts. We did not observe any episodes of acute rejection, and there were few adverse events. Drug tolerance was good for both immunosuppression and antiretroviral therapies. CONCLUSION: Kidney transplantation in HIV-positive patients with ESRD is warranted. Provided that patients are carefully selected, good results can be achieved with few adverse events, episodes of acute rejection, and drug interactions. Posttransplantation, these patients must be closely monitored by both the transplantation and infectious diseases teams to ensure optimal management.

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OBJECTIVES: The objective of this study was to determine if the ultrasound probe can act as a vector for cross-infection and to compare two cleaning methods for ultrasound probes in order to limit or control the transmission risk. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: The first part of the study (P1) was conducted to evaluate the possibility of the ultrasound probe to serve as a source of cross-contamination. Thirty blocks were placed under ultrasound guidance in elective outpatients. After each procedure (Proc), the ultrasound probe was decontaminated/cleaned using either an antiseptic solution spray (AS: n=15) or just wiped with two dry paper sheets (DP: n=15), in a randomly assigned order. Bacteriological samples were collected before and after each decontamination/cleaning methods and inoculated on a chocolate agar plates. The second part of the study (P2) was conducted to compare the effectiveness of two cleaning methods for ultrasound probes. The ultrasound probes were exposed to a large inoculum of three bacteria (Inoc). They were then cleaned/decontaminated using either DP (n=10) or AS (n=10), in a randomly assigned order. Bacteriological samples were collected before and after each cleaning/decontamination methods and inoculated on a chocolate agar plates. RESULTS: During P1, after Pro, all probes were found to be sterile before and after both AS and DP. During P2, after Inoc, all probes were found infected (CFU>150) but were considered sterile (CFU<10) after both DP and AS. CONCLUSION: The results of this study suggest that the risk of cross-infection during ultrasound guidance in locoregional anaesthesia is really low. Our data suggest that wiping ultrasound probe with two dry paper sheets is an adequate cleaning method to prevent cross-contamination risk.

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INTRODUCTION: Few information are available regarding the learning curve in ultrasonography and even less for ultrasound-guided regional anesthesia. This study aimed to evaluate in a training program the learning curve on a phantom of 12 residents novice in ultrasonography. MATERIAL AND METHODS: Twelve trainees inexperienced in ultrasonography were given introductory training consisting of didactic formation on the various components of the portable ultrasound machine (i.e. on/off button, gain, depth, resolution, and image storage). Then, students performed three trials, in two sets of increased difficulty, at executing these predefined tasks: adjustments of the machine, then localization of a small plastic piece introduced into roasting pork (3 cm below the surface). At the end of the evaluation, the residents were asked to insert a 22 G needle into an exact predetermined target (i.e. point of fascia intersection). The progression of the needle was continuously controlled by ultrasound visualization using injection of a small volume of water (needle perpendicular to the longitudinal plane of the ultrasound beam). Two groups of two different examiners evaluated for each three trials the skill of the residents (quality, time to perform the machine adjustments, to localize the plastic target, and to hydrolocalize, and volume used for hydrolocalization). After each trial, residents evaluated their performance using a difficulty scale (0: easy to 10: difficult). RESULTS: All residents performed the adjustments from the last trial of each set, with a learning curve observed in terms of duration. Localization of the plastic piece was achieved by all residents at the 6th trial, with a shorter duration of localization. Hydrolocalization was achieved after the 4th trial by all subjects. Difficulty scale was correlated to the number of trials. All these results were independent of the experience of residents in regional anesthesia. DISCUSSION: Four trials were necessary to adjust correctly the machine, to localize a target, and to complete hydrolocalization. Ultrasonography in regional anesthesia seems to be a fast-learning technique, using this kind of practical training.

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Accidental dislodgement of continuous peripheral nerve catheters remains a frequent problem that causes failure of postoperative analgesia. We have assessed the use of new synthetic glue (Mastisol) to secure and maintain catheters in the correct position among 60 patients. This method allowed securing an effective fixation in 94% of cases,resulting in efficient ambulatory orthopedic surgery postoperative analgesia. No nervous or infectious complications were observed. This technique offers a simple, complementary method to secure peripheral nerve catheters.

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INTRODUCTION: Anemia remains frequent in the first month following renal transplantation and is a risk factor for cardiovascular accidents. The purpose of this study was to analyze the prevalence of anemia during this period notably among different immunosuppressive treatment groups. METHODS: In this study, we entered the patients who had received a renal allograft in our transplant unit from 1993 to 2003, including patients who had received azathioprine (AZA) from 1993 to 1996 and mycophenolate mofetil (MMF) from 1996 to 2003. No patient received rHu-erythropoietin after transplantation during that period. A mathematical model normalized the hemoglobin (Hb) threshold level at which blood transfusion was decided and Hb on admission. RESULTS: One hundred and eighty-eight patients on AZA and 223 on MMF were included in the analysis. The mean age +/- SD was 41 +/- 12 years in the AZA group, and 45 +/- 12 years in the MMF group (P < .006). Before the transplantation, Hb was higher in the MMF group (11.4 +/- 1.9 vs 10.2 +/- 2 g/dL, P < .0001). After normalization at a threshold level of transfusion of 7 g/dL, transfusions were more frequent among the MMF group (72% vs 48%, P < .0001). Double therapy with MMF (1500 mg/d) + steroids or therapy with MMF (750 mg/d) + tacrolimus + steroids increased the risk of transfusion compared to the AZA group. MMF (750 mg/d) + cyclosporine conferred a similar risk of transfusion compared with the AZA group. CONCLUSION: MMF alone or in association with tacrolimus is associated with an increased risk of anemia and transfusion in the immediate posttransplantation period.

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OBJECTIVES: To assess the feasibility of neurostimulation and ultrasound guidance combination for infraclavicular brachial plexus block (ICB) technique. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: Fifty consecutive patients scheduled for hand, forearm or elbow surgery were included. METHODS: A single stimulation lateral approach technique of ICB was performed. During the procedure, neurostimulation and ultrasound guidance were combined. The feasibility of ICB was assessed using a visual analogue scale (VAS, 0: impossible, 100: very simple) for ultrasound anatomical structures identification (VAS(Anat)) and for block placement (VAS (Block)). The success rate of ICB block was noted. RESULTS: No patient required general anaesthesia conversion. Median VAS+/-SD of VAS(Anat) and VAS(Block) were of 84+/-15 and 96+/-7, respectively. Success rate of ICB was 96%. No specific complication of ICB technique was noted. CONCLUSION: Combination of neurostimulation and ultrasound guidance is feasible. Combination of neurostimulation and ultrasound guidance secured ICB. Ultrasound-evidenced spread of local anaesthetics increased the success rate of ICB.

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The optical blood volume curve sometimes presents either a positive or a negative rapid and reversible variation (spike) during the step of the dialysate conductivity, automatically set by the monitor for the ionic dialysance (ID) measurement. We studied whether this feature was in relation with access recirculation. Firstly, we studied if the manoeuvre of reversed position of the blood lines created the same feature in the blood volume curve. Secondly, two medical teams systematically checked for the presence of spikes and measured the access recirculation by way of an ultrasound dilution technique. The manoeuvre of reversed position of the blood lines invariably reproduced the same feature on the curve of the optical blood volume measurement in case of a recirculation greater than 20%. In the normal position of the blood lines, the 16 patients with an access recirculation greater than 20% had spikes. Spikes during ID measurement were not constant for an access recirculation between 10 and 20% and did not occur for an access recirculation of less than 10% or an undetectable one. The special spike of the optical blood volume curve occurring during the ID measurement clearly detects access recirculation. The specificity is of 100% when this modification is present all along the dialysis session for all the ID measurements and the sensitivity is 100% when the access recirculation is greater than 20%.

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We report the case of an association of IgA nephropathy and tuberculosis with superimposed vasculitis lesions on the renal biopsy. Three previous cases of the same association are discussed. The nephropathy had a favorable course in all of these cases on antituberculous treatment only. Tuberculosis is another infection related to IgA nephropathy.

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OBJECTIVES: To assess the efficiency of a posterior secondary trunk single stimulation, low volume (30 ml 1.5% mepivacaine) infraclavicular brachial plexus block (ICB) technique. STUDY DESIGN: Prospective study. PATIENTS AND METHODS: One hundred consecutive patients scheduled for hand, forearm or elbow surgery were included. ICB was placed using a single stimulation technique. 30 ml 1.5% mepivacaine was injected when an evoked distal radial motor type response was elicited for 0.3-0.6 mA intensity current. Based upon both sensory and motor distribution ICB, characteristics and performance were assessed. RESULTS: No patient required general anesthesia conversion. Success rate was 92%. 8 patients required a total amount of 10 complementary distal troncular blocks. No specific complication of ICB technique was accoutered. All patients completed full neurological recovery from ICB 24 hours after surgery. CONCLUSION: 30 ml mepivacaine 1.5% ICB is suitable for upper limb surgery.

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UNLABELLED: The task of dialysis therapy is, amongst other things, to remove excess potassium (K+) from the body. The need to achieve an adequate K+ removal with the risk of cardiac arrhythmias due to sudden intra-extracellular K+ gradient advises the distribution of the removal throughout the dialysis session instead of just in the first half. The aim of the study was to investigate the electrical behavior of two different K+ removal rates on myocardial cells (risk of arrhythmia and ECG alterations). Constant acetate-free biofiltration (AFB) and profiled K+ (decreasing during the treatment) AFB (AFBK) were used in a patient sample to understand, first of all, the effect on premature ventricular contraction (PVC) and on repolarization indices [QT dispersion (QTd) and principal component analysis (PCA)]. The study was divided into two phases: phase 1 was a pilot study to evaluate K+ kinetics and to test the effect on the electrophysiological response of the two procedures. The second phase was set up as an extended cross-over multicenter trial in patient subsets prone to arrhythmias during dialysis. Phase 1: PVC increased during both AFB and AFBK but less in the latter in the middle of dialysis (298 in AFB vs. 200 in AFBK). The PVC/h in a subset of arrhythmic patients was 404 +/- 145 in AFB and 309 +/- 116 in AFBK (p = 0.0028). QT interval (QTc) prolongation was less pronounced in AFBK than in AFB. Phase 2: The PVC again increased in both AFB and AFBK but less in the latter mid-way through dialysis (79 +/- 19 AFB vs. 53 +/- 13 AFBK). Moreover, in the most arrhythmic patients the benefit accruing from the smooth K+ removal rate was more pronounced (103 +/- 19 in AFB vs. 78 +/- 13 in AFBK). CONCLUSION: It is not the K+ dialysis removal alone that can be destabilizing from an electrophysiological standpoint, but rather its removal dynamics. This is all the more evident in patients with arrhythmias who benefit from the K+ profiling during their dialysis treatment.

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We report the third case in the literature of a patient with a long-lasting renal allograft who experienced tuberculosis just after the switch from azathioprine to mycophenolate mofetil. The switch was likely responsible for the reactivation of dormant tuberculosis; prophylactic antituberculous treatment should be considered in cases of such a therapeutic change.

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INTRODUCTION: Vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA) have been reported in patients suffering from Graves' disease treated with anti-thyroid drugs and especially propylthiouracil (PTU). EXEGESIS: We report a case of Graves' disease treated with benzylthiouracil (Basdène). This therapy was complicated by acute renal insufficiency due to crescentic glomerulonephritis associated with pANCA. After benzylthiouracil withdrawal and under corticosteroids, renal insufficiency, biological inflammation and pANCA levels decreased. CONCLUSION: Similar vasculitis associated with pANCA secondary to anti-thyroid drugs, especially propylthiouracil, were described. This suggests a causal relation between drug and vasculitis. To our best knowledge, it is the first case of vasculitis secondary to benzylthiouracil.

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Amphotericin B is widely used for severe life threatening fungal infections. Its use is limited by a dose-dependent nephrotoxicity manifested by a reduction in glomerular filtration rate and tubular dysfunction. An elevated creatinine associated with amphotericin B is not only a marker for renal dysfunction but is also linked to a substantial risk for the use of hemodialysis and a higher mortality rate; therefore amphotericin B nephrotoxicity is not a benign complication and its prevention is essential. Several manipulations have been proposed to try and minimize amphotericin B induced nephrotoxicity. Systematic hydration is crucial to minimize amphotericin B. Mannitol or intralipids administration were once suggested as protective based on anecdotal observational reports. Small prospective and randomized trials, however did not support a protective effect. Three new formulations have been developed in an attempts to improse both efficacy and tolerability: amphotericin B in lipid complex (ABLC, Abelcet). Colloidal dispersion (ABCD, Amphotec and amphotericin B liposome (Ambisome). Three prospectives randomized studies have clearly shown that Ambisome is less nephrotoxic than amphotericin B. Unfortunately the only randomized trial comparing Abelcet with amphotericin B is an open-label treatment of invasive candidiasis which was presented 5 years ago but never published as a full paper. Furthermore in a recent multicenter double-blind study it has been shown that Ambisome has a better safety profile than Abelcet with less chills/rigors and less nephrotocixity.

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