Purpose: Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity and... more Purpose: Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity and mortality. Norepinephrine is often use to treat IOH. However, the question regarding the mode of administration in either a bolus or continuous infusion (CI) remains unanswered. The aim of the present study was to describe and compare the effects on macrocirculation and microcirculation of a bolus and a CI of norepinephrine to treat IOH.Methods: We conducted a prospective observational study with adult patients who underwent neurosurgery. Patients with invasive arterial blood pressure and cardiac output (CO) monitoring were screened for inclusion. All patients underwent microcirculation monitoring by video capillaroscopy, laser doppler, near-infrared spectroscopy technology, and tissue CO2. In case of IOH, the patient could receive either a bolus of 10 µg or a CI of 200 µg/h of norepinephrine.Results: Thirty-six patients were included, with 41 boluses and 33 CI.Bolus and CI induced an i...
Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theat... more Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theatre allows us to draw velocity-pressure (Vel-Pre) loops. The global afterload angle (GALA), derived from the Vel-Pre loops, has been linked to cardiac afterload indicators. As age is the major determinant of constitutive arterial stiffness, we aimed to describe (1) the evolution of the GALA according to age in a large cohort of anesthetized patients and (2) GALA variations induced by haemodynamic interventions. We included patients for whom continuous monitoring of arterial pressure and cardiac output were indicated. Fluid challenges or vasopressors were administered to treat intra-operative hypotension. The primary endpoint was the comparison of the GALA values between young and old patients. The secondary endpoint was the difference in the GALA values before and after haemodynamic interventions. We included 133 anaesthetized patients: 66 old and 67 young patients. At baseline, the GALA was higher in the old patients than in young patients (38 ± 6 vs. 25 ± 4 degrees; p < 0.001). The GALA was positively associated with age (p < 0.001), but the mean arterial pressure (MAP) and cardiac output were not. The GALA did not change after volume expansion, regardless of the fluid response, but it did increase after vasopressor administration. Furthermore, while a vasopressor bolus led to a similar increase in MAP, phenylephrine induced a more substantial increase in the GALA than noradrenaline (+ 12 ± 5° vs. + 8 ± 5°; p = 0.01). In non-cardiac surgery, the GALA seems to be associated with both intrinsic rigidity (reflected by age) and pharmacologically induced vasoconstriction changes (by vasopressors). In addition, the GALA can discriminate the differential effects of phenylephrine and noradrenaline. These results should be confirmed in a prospective, ideally randomized, trial.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Background Global afterload angle (GALA) is a parameter derived from velocity-pressure loop (VP L... more Background Global afterload angle (GALA) is a parameter derived from velocity-pressure loop (VP Loop), for continuous assessment of cardiac afterload in the operating room. It has been validated with invasive measure of central pressure. The aim of this study was to evaluate the feasibility of noninvasive VP Loop obtained with central pressure measured with two different noninvasive tonometers. Methods A prospective, observational, monocentric study was conducted in 51 patients under general anesthesia. Invasive central pressure (cP INV) was measured with a fulfilled intravascular catheter, and noninvasive central pressure signals were obtained with two applanation tonometry devices: radial artery tonometry (cP SHYG : Sphygmocor tonometer) and carotid tonometry (cP COMP : Complior tonometer). Three VP Loops were built: VP Loop INV , VP Loop SPHYG and VP Loop COMP. Patients were separated according to cardiovascular risk factors. Results In the 51 patients under general anesthesia, cP SHYG was adequately obtained in 48 patients (89%) but, compared to cP INV , SBP was underestimated (−4 ± 6 mmHg, P < 0.0001), augmentation index (AIX SPHYG) and a GALA SPHYG were overestimated (+13 ± 19%, P = 0.0077 and +4 ± 8°, P = 0.0024, respectively) with large limit of agreement (LOA) (−21 to 47% and −13 to 21° for AIX SPHYG and GALA SPHYG , respectively). With the Complior, the failure rate of measurement for cP COMP was 41%. SBP was similar (3 ± 17 mmHg, P = 0.32), AIX COMP was underestimated (−11 ± 19%, P = 0.0046) and GALA COMP was similar but with large LOA (−50 to 26% and −20 to 18° for AIX COMP and GALA COMP , respectively). Conclusion In anesthetized patient, the reliability of noninvasive central pressure monitoring by tonometry seems too limited to monitor cardiac afterload with VP Loop.
American Journal of Physiology-Heart and Circulatory Physiology, 2019
Cardiac afterload is usually assessed in the ascending aorta and can be defined by the associatio... more Cardiac afterload is usually assessed in the ascending aorta and can be defined by the association of peripheral vascular resistance (PVR), total arterial compliance (Ctot), and aortic wave reflection (WR). We recently proposed the global afterload angle (GALA) and β-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta. The aim of this study was to 1) describe the arterial mechanic properties by studying the velocity-pressure relations according to cardiovascular risk (low-risk and high-risk patients) in the ascending and descending thoracic aorta and 2) analyze the association between the VP loop (GALA and β-angle) and cardiac afterload parameters (PVR, Ctot, and WR). PVR, Ctot, WR, and VP loop parameters were measured in the ascending and descending thoracic aorta in 50 anesthetized patients. At each aortic level, the mean arterial pressure (MAP), cardiac output (CO), and PVR were similar between low-...
La nécessité de recourir à une chirurgie peut précipiter la survenue d'un événement cardiaque, le... more La nécessité de recourir à une chirurgie peut précipiter la survenue d'un événement cardiaque, le risque est d'autant plus important que le patient pris en charge est porteur d'une insuffisance cardiaque connue. L'anémie est un facteur favorisant l'ischémie myocardique. Le seuil d'hémoglobine en-deçà duquel il conviendrait de transfuser les patients, en particulier les insuffisants cardiaques, fait l'objet de débat. La stratégie transfusionnelle doit être adaptée en fonction de l'évaluation pré-opératoire du saignement attendu, du débit per-opératoire de saignement, et du risque du patient. Il est donc important chez tout patient insuffisant cardiaque, d'avoir recours à un monitorage le plus multimodal possible afin de respecter au plus près des « cibles hémodynamiques », incluant une surveillance de l'hémoglobine.
Lateral venous sinus stenoses have been associated with idiopathic intracranial hypertension and ... more Lateral venous sinus stenoses have been associated with idiopathic intracranial hypertension and venous pulsatile tinnitus. Venous pressure measurement is traditionally performed to assess the indications for stenting in patients with idiopathic intracranial hypertension. However, its reliability has recently been questioned by many authors. The dual-sensor guidewire was first developed for advanced physiological assessment of fractional and coronary flow reserves in coronary artery stenoses. It allows measurement of both venous pressure and blood flow velocities. The authors used this device in 14 consecutively treated patients to explore for symptomatic lateral sinus stenosis. They found that venous blood flow was significantly accelerated inside the stenotic lesion. This acceleration, as well as the pulsatile tinnitus, resolved in all patients following stent placement. According to the authors’ results, this guidewire can be helpful for establishing an indication for stenting in...
Introduction Le thromboendarteriectomie pulmonaire (TEP) est le traitement de choix de l’hyperten... more Introduction Le thromboendarteriectomie pulmonaire (TEP) est le traitement de choix de l’hypertension arterielle pulmonaire chronique post-embolique. Un œdeme de reperfusion severe peut parfois compliquer l’evolution postoperatoire. Les effets benefiques du decubitus ventral (DV) ont ete demontres au cours des SDRA severe. Cependant dans cette population particuliere avec une dysfonction ventriculaire droite pre- et postoperatoire immediate et un oedeme pulmonaire de mecanisme complexe, les resultats de la mise en DV sont mal connus. Le but de cette etude est de rapporter les effets du DV sur les parametres respiratoires et hemodynamiques apres TEP. Patients et methodes Du 15 juillet 2011 au 22 aout 2013, 261 patients ont ete operes d’une TEP. Les patients ayant necessite une mise en DV ont ete prospectivement identifies. Les parametres ventilatoires et hemodynamiques ont ete retrospectivement colliges avant, pendant et apres la seance de DV, de meme que le score de defaillance viscerale SOFA et le score de radiologie. Le devenir de ces patients a ete note. Une analyse de variance (Anova) a ete realisee pour etudier l’evolution des parametres hemodynamiques et ventilatoires. Resultats Durant la periode de l’etude, la mise sous DV a concerne 17 patients (6,5 %) âges de 67 ± 11 ans (10 hommes, 6 femmes), avec une mediane de 6,0 jours [interquartile range (IQR) 4,0–13,5] apres la TEP pour un total de 38 seances. La mediane de seances de DV etait de 3 [IQR 2–3] pour une duree mediane de 17,5 heures [IQR 15,2–21,0]. La pression arterielle pulmonaire moyenne preoperatoire etait de 48 ± 11 mmHg pour un debit cardiaque de 4,6 ± 0,9 L/min. Les resultats hemodynamiques et ventilatoires avant, pendant et apres le DV sont resumes dans le Tableau 1 . Le volume courant moyen etait de 6,7 ± 0,6 mL/kg de poids ideal pour une frequence respiratoire moyenne de 28 ± 4 et une pression expiratoire positive optimale de 9,7 ± 5,7 mmHg. Le score radiologique s’ameliore significativement apres le DV (4,8 ± 1,5 vs 3,9 ± 1,6 ; p = 0,0008). Le recours a une ECMO a concerne 9 patients. Il y a eu 10 deces. Discussion La mise sous DV n’a pas eu de consequences negatives en terme de tolerance hemodynamique. L’amelioration des parametres ventilatoires a concerne un peu moins de la moitie des patients, l’autre moitie devant beneficier de la mise sous ECMO. La mise sous DV est une option therapeutique licite chez des patients hypoxemiques apres TEP. La non reponse des parametres ventilatoires au DV doit faire envisager rapidement la mise sous ECMO.
Introduction La thromboendarteriectomie pulmonaire (TEP) pour cœur pulmonaire chronique (CPC) ind... more Introduction La thromboendarteriectomie pulmonaire (TEP) pour cœur pulmonaire chronique (CPC) induit une hypoxemie aigue postoperatoire parfois severe necessitant le recours a une ventilation protectrice (VM). L’effet benefique d’une pression expiratoire positive (PEP) pourrait etre modifie par la defaillance du VD. Cette etude retrospective observationnelle a pour but d’evaluer la tolerance hemodynamique et le benefice de differents niveaux de PEP chez les patients ayant un SDRA en postoperatoire precoce d’une TEP. Patients et methodes Les patients (pts) inclus sont les adultes ayant beneficie d’une TEP de fevrier 2011 a janvier 2014 dans notre centre. Les donnees des pts ayant eu un SDRA precoce (criteres a j0 et j1) et ventiles plus de 7 jours, ont ete analysees. Sous VM (Vt 6 mL/kg, PP 2 O), la PEP reglee a 15 cmH 2 O etait diminuee par palier de 5 cm toute les 15 min jusqu’a 0, un gaz du sang etait preleve a chaque palier. La PEP optimale est celle associee a la meilleure PO 2 , en l’absence de consequences majeures hemodynamiques (chute de la pression arterielle systemique (PA) non reversible par une majoration de 50 % de la dose de vasopresseurs). Les donnees preoperatoires (catheterisme cardiaque droit (KTD), echographie cardiaque) et postoperatoires (PO 2 /FiO 2 , KTD, PA, vasopresseurs) ont ete recueillies, ainsi que l’etiologie du SDRA, le score radiologique, le score SOFA a j1 et j3 apres application de la PEP. Resultats Durant la periode etudiee 208 pts ont beneficie d’une TEP, compliquee d’un SDRA dans 15 % (31 pts) dont deux tiers en postoperatoire precoce (20 pts). Les pts etudies (11 femmes, 9 hommes) ont un âge moyen de 65 ± 11 ans, un CPC severe (valeur moyenne ± ecart-type de la PAP 49 ± 12 mmHg, du DC 4,2 ± 1,0 L/min, de la RVP 938 ± 323 dynes.s.cm −5 et dysfonction preoperatoire systolique du VD moyenne ou importante chez 90 % des pts). Les etiologies du SDRA sont un œdeme de reperfusion (77 %) et/ou une pneumopathie bacterienne (70 %). Selon les criteres definis, la PEP optimale etait de 15 cmH 2 O pour 12 pts, 10 cmH 2 O pour 7 pts et 5 cmH 2 O pour 1 pt. Durant le test de PEP, la FC et la PA sont non modifies. Le Tableau 1 presente l’evolution des parametres hemodynamiques et ventilatoires de j0 a j3 apres application de la PEP optimale. Les pts avec PEP 15 cmH 2 O avaient une dysfonction systolique preoperatoire du VD similaire a celle des pts avec PEP ≤ 10 cmH 2 O, et une fraction d’ejection preoperatoire du VG comparable (68 % et 58 % respectivement, p = 0,07). Discussion L’application de niveau de PEP ≥ 10 permet l’amelioration de l’hematose en postoperatoire precoce de TEP pour CPC compliquee de SDRA, sans element de mauvaise tolerance hemodynamique, malgre la defaillance preoperatoire du VD.
Purpose: Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity and... more Purpose: Intraoperative arterial hypotension (IOH) leads to increased postoperative morbidity and mortality. Norepinephrine is often use to treat IOH. However, the question regarding the mode of administration in either a bolus or continuous infusion (CI) remains unanswered. The aim of the present study was to describe and compare the effects on macrocirculation and microcirculation of a bolus and a CI of norepinephrine to treat IOH.Methods: We conducted a prospective observational study with adult patients who underwent neurosurgery. Patients with invasive arterial blood pressure and cardiac output (CO) monitoring were screened for inclusion. All patients underwent microcirculation monitoring by video capillaroscopy, laser doppler, near-infrared spectroscopy technology, and tissue CO2. In case of IOH, the patient could receive either a bolus of 10 µg or a CI of 200 µg/h of norepinephrine.Results: Thirty-six patients were included, with 41 boluses and 33 CI.Bolus and CI induced an i...
Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theat... more Continuous measurement of aortic pressure and aortic flow velocity signals in the operating theatre allows us to draw velocity-pressure (Vel-Pre) loops. The global afterload angle (GALA), derived from the Vel-Pre loops, has been linked to cardiac afterload indicators. As age is the major determinant of constitutive arterial stiffness, we aimed to describe (1) the evolution of the GALA according to age in a large cohort of anesthetized patients and (2) GALA variations induced by haemodynamic interventions. We included patients for whom continuous monitoring of arterial pressure and cardiac output were indicated. Fluid challenges or vasopressors were administered to treat intra-operative hypotension. The primary endpoint was the comparison of the GALA values between young and old patients. The secondary endpoint was the difference in the GALA values before and after haemodynamic interventions. We included 133 anaesthetized patients: 66 old and 67 young patients. At baseline, the GALA was higher in the old patients than in young patients (38 ± 6 vs. 25 ± 4 degrees; p < 0.001). The GALA was positively associated with age (p < 0.001), but the mean arterial pressure (MAP) and cardiac output were not. The GALA did not change after volume expansion, regardless of the fluid response, but it did increase after vasopressor administration. Furthermore, while a vasopressor bolus led to a similar increase in MAP, phenylephrine induced a more substantial increase in the GALA than noradrenaline (+ 12 ± 5° vs. + 8 ± 5°; p = 0.01). In non-cardiac surgery, the GALA seems to be associated with both intrinsic rigidity (reflected by age) and pharmacologically induced vasoconstriction changes (by vasopressors). In addition, the GALA can discriminate the differential effects of phenylephrine and noradrenaline. These results should be confirmed in a prospective, ideally randomized, trial.
This is a PDF file of an article that has undergone enhancements after acceptance, such as the ad... more This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Background Global afterload angle (GALA) is a parameter derived from velocity-pressure loop (VP L... more Background Global afterload angle (GALA) is a parameter derived from velocity-pressure loop (VP Loop), for continuous assessment of cardiac afterload in the operating room. It has been validated with invasive measure of central pressure. The aim of this study was to evaluate the feasibility of noninvasive VP Loop obtained with central pressure measured with two different noninvasive tonometers. Methods A prospective, observational, monocentric study was conducted in 51 patients under general anesthesia. Invasive central pressure (cP INV) was measured with a fulfilled intravascular catheter, and noninvasive central pressure signals were obtained with two applanation tonometry devices: radial artery tonometry (cP SHYG : Sphygmocor tonometer) and carotid tonometry (cP COMP : Complior tonometer). Three VP Loops were built: VP Loop INV , VP Loop SPHYG and VP Loop COMP. Patients were separated according to cardiovascular risk factors. Results In the 51 patients under general anesthesia, cP SHYG was adequately obtained in 48 patients (89%) but, compared to cP INV , SBP was underestimated (−4 ± 6 mmHg, P < 0.0001), augmentation index (AIX SPHYG) and a GALA SPHYG were overestimated (+13 ± 19%, P = 0.0077 and +4 ± 8°, P = 0.0024, respectively) with large limit of agreement (LOA) (−21 to 47% and −13 to 21° for AIX SPHYG and GALA SPHYG , respectively). With the Complior, the failure rate of measurement for cP COMP was 41%. SBP was similar (3 ± 17 mmHg, P = 0.32), AIX COMP was underestimated (−11 ± 19%, P = 0.0046) and GALA COMP was similar but with large LOA (−50 to 26% and −20 to 18° for AIX COMP and GALA COMP , respectively). Conclusion In anesthetized patient, the reliability of noninvasive central pressure monitoring by tonometry seems too limited to monitor cardiac afterload with VP Loop.
American Journal of Physiology-Heart and Circulatory Physiology, 2019
Cardiac afterload is usually assessed in the ascending aorta and can be defined by the associatio... more Cardiac afterload is usually assessed in the ascending aorta and can be defined by the association of peripheral vascular resistance (PVR), total arterial compliance (Ctot), and aortic wave reflection (WR). We recently proposed the global afterload angle (GALA) and β-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta. The aim of this study was to 1) describe the arterial mechanic properties by studying the velocity-pressure relations according to cardiovascular risk (low-risk and high-risk patients) in the ascending and descending thoracic aorta and 2) analyze the association between the VP loop (GALA and β-angle) and cardiac afterload parameters (PVR, Ctot, and WR). PVR, Ctot, WR, and VP loop parameters were measured in the ascending and descending thoracic aorta in 50 anesthetized patients. At each aortic level, the mean arterial pressure (MAP), cardiac output (CO), and PVR were similar between low-...
La nécessité de recourir à une chirurgie peut précipiter la survenue d'un événement cardiaque, le... more La nécessité de recourir à une chirurgie peut précipiter la survenue d'un événement cardiaque, le risque est d'autant plus important que le patient pris en charge est porteur d'une insuffisance cardiaque connue. L'anémie est un facteur favorisant l'ischémie myocardique. Le seuil d'hémoglobine en-deçà duquel il conviendrait de transfuser les patients, en particulier les insuffisants cardiaques, fait l'objet de débat. La stratégie transfusionnelle doit être adaptée en fonction de l'évaluation pré-opératoire du saignement attendu, du débit per-opératoire de saignement, et du risque du patient. Il est donc important chez tout patient insuffisant cardiaque, d'avoir recours à un monitorage le plus multimodal possible afin de respecter au plus près des « cibles hémodynamiques », incluant une surveillance de l'hémoglobine.
Lateral venous sinus stenoses have been associated with idiopathic intracranial hypertension and ... more Lateral venous sinus stenoses have been associated with idiopathic intracranial hypertension and venous pulsatile tinnitus. Venous pressure measurement is traditionally performed to assess the indications for stenting in patients with idiopathic intracranial hypertension. However, its reliability has recently been questioned by many authors. The dual-sensor guidewire was first developed for advanced physiological assessment of fractional and coronary flow reserves in coronary artery stenoses. It allows measurement of both venous pressure and blood flow velocities. The authors used this device in 14 consecutively treated patients to explore for symptomatic lateral sinus stenosis. They found that venous blood flow was significantly accelerated inside the stenotic lesion. This acceleration, as well as the pulsatile tinnitus, resolved in all patients following stent placement. According to the authors’ results, this guidewire can be helpful for establishing an indication for stenting in...
Introduction Le thromboendarteriectomie pulmonaire (TEP) est le traitement de choix de l’hyperten... more Introduction Le thromboendarteriectomie pulmonaire (TEP) est le traitement de choix de l’hypertension arterielle pulmonaire chronique post-embolique. Un œdeme de reperfusion severe peut parfois compliquer l’evolution postoperatoire. Les effets benefiques du decubitus ventral (DV) ont ete demontres au cours des SDRA severe. Cependant dans cette population particuliere avec une dysfonction ventriculaire droite pre- et postoperatoire immediate et un oedeme pulmonaire de mecanisme complexe, les resultats de la mise en DV sont mal connus. Le but de cette etude est de rapporter les effets du DV sur les parametres respiratoires et hemodynamiques apres TEP. Patients et methodes Du 15 juillet 2011 au 22 aout 2013, 261 patients ont ete operes d’une TEP. Les patients ayant necessite une mise en DV ont ete prospectivement identifies. Les parametres ventilatoires et hemodynamiques ont ete retrospectivement colliges avant, pendant et apres la seance de DV, de meme que le score de defaillance viscerale SOFA et le score de radiologie. Le devenir de ces patients a ete note. Une analyse de variance (Anova) a ete realisee pour etudier l’evolution des parametres hemodynamiques et ventilatoires. Resultats Durant la periode de l’etude, la mise sous DV a concerne 17 patients (6,5 %) âges de 67 ± 11 ans (10 hommes, 6 femmes), avec une mediane de 6,0 jours [interquartile range (IQR) 4,0–13,5] apres la TEP pour un total de 38 seances. La mediane de seances de DV etait de 3 [IQR 2–3] pour une duree mediane de 17,5 heures [IQR 15,2–21,0]. La pression arterielle pulmonaire moyenne preoperatoire etait de 48 ± 11 mmHg pour un debit cardiaque de 4,6 ± 0,9 L/min. Les resultats hemodynamiques et ventilatoires avant, pendant et apres le DV sont resumes dans le Tableau 1 . Le volume courant moyen etait de 6,7 ± 0,6 mL/kg de poids ideal pour une frequence respiratoire moyenne de 28 ± 4 et une pression expiratoire positive optimale de 9,7 ± 5,7 mmHg. Le score radiologique s’ameliore significativement apres le DV (4,8 ± 1,5 vs 3,9 ± 1,6 ; p = 0,0008). Le recours a une ECMO a concerne 9 patients. Il y a eu 10 deces. Discussion La mise sous DV n’a pas eu de consequences negatives en terme de tolerance hemodynamique. L’amelioration des parametres ventilatoires a concerne un peu moins de la moitie des patients, l’autre moitie devant beneficier de la mise sous ECMO. La mise sous DV est une option therapeutique licite chez des patients hypoxemiques apres TEP. La non reponse des parametres ventilatoires au DV doit faire envisager rapidement la mise sous ECMO.
Introduction La thromboendarteriectomie pulmonaire (TEP) pour cœur pulmonaire chronique (CPC) ind... more Introduction La thromboendarteriectomie pulmonaire (TEP) pour cœur pulmonaire chronique (CPC) induit une hypoxemie aigue postoperatoire parfois severe necessitant le recours a une ventilation protectrice (VM). L’effet benefique d’une pression expiratoire positive (PEP) pourrait etre modifie par la defaillance du VD. Cette etude retrospective observationnelle a pour but d’evaluer la tolerance hemodynamique et le benefice de differents niveaux de PEP chez les patients ayant un SDRA en postoperatoire precoce d’une TEP. Patients et methodes Les patients (pts) inclus sont les adultes ayant beneficie d’une TEP de fevrier 2011 a janvier 2014 dans notre centre. Les donnees des pts ayant eu un SDRA precoce (criteres a j0 et j1) et ventiles plus de 7 jours, ont ete analysees. Sous VM (Vt 6 mL/kg, PP 2 O), la PEP reglee a 15 cmH 2 O etait diminuee par palier de 5 cm toute les 15 min jusqu’a 0, un gaz du sang etait preleve a chaque palier. La PEP optimale est celle associee a la meilleure PO 2 , en l’absence de consequences majeures hemodynamiques (chute de la pression arterielle systemique (PA) non reversible par une majoration de 50 % de la dose de vasopresseurs). Les donnees preoperatoires (catheterisme cardiaque droit (KTD), echographie cardiaque) et postoperatoires (PO 2 /FiO 2 , KTD, PA, vasopresseurs) ont ete recueillies, ainsi que l’etiologie du SDRA, le score radiologique, le score SOFA a j1 et j3 apres application de la PEP. Resultats Durant la periode etudiee 208 pts ont beneficie d’une TEP, compliquee d’un SDRA dans 15 % (31 pts) dont deux tiers en postoperatoire precoce (20 pts). Les pts etudies (11 femmes, 9 hommes) ont un âge moyen de 65 ± 11 ans, un CPC severe (valeur moyenne ± ecart-type de la PAP 49 ± 12 mmHg, du DC 4,2 ± 1,0 L/min, de la RVP 938 ± 323 dynes.s.cm −5 et dysfonction preoperatoire systolique du VD moyenne ou importante chez 90 % des pts). Les etiologies du SDRA sont un œdeme de reperfusion (77 %) et/ou une pneumopathie bacterienne (70 %). Selon les criteres definis, la PEP optimale etait de 15 cmH 2 O pour 12 pts, 10 cmH 2 O pour 7 pts et 5 cmH 2 O pour 1 pt. Durant le test de PEP, la FC et la PA sont non modifies. Le Tableau 1 presente l’evolution des parametres hemodynamiques et ventilatoires de j0 a j3 apres application de la PEP optimale. Les pts avec PEP 15 cmH 2 O avaient une dysfonction systolique preoperatoire du VD similaire a celle des pts avec PEP ≤ 10 cmH 2 O, et une fraction d’ejection preoperatoire du VG comparable (68 % et 58 % respectivement, p = 0,07). Discussion L’application de niveau de PEP ≥ 10 permet l’amelioration de l’hematose en postoperatoire precoce de TEP pour CPC compliquee de SDRA, sans element de mauvaise tolerance hemodynamique, malgre la defaillance preoperatoire du VD.
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