L’optimisation hémodynamique repose sur toutes les mesures thérapeutiques ou de surveillance qui permettent de promouvoir l’oxygénation tissulaire avant, pendant et après un acte chirurgical réglé ou urgent. Récemment, plusieurs essais cliniques ont permis de faire progresser les connaissances sur la place des moyens de monitorage hémodynamique au bloc opératoire, mais également concernant la conduite de l’expansion volémique, l’utilisation des vasopresseurs et des inotropes. Les grands principes de l’optimisation hémodynamique ont été rappelés récemment par des recommandations formalisées d’expert (RFE) de la Société française d’anesthésie réanimation (SFAR). Au travers de cette mise au point, nous proposons d’évoquer le rationnel scientifique qui entoure certaines de ces recommandations afin d’éclairer les médecins anesthésistes réanimateurs sur les points suivants : l’évaluation du risque périopératoire, le choix du moyen de monitorage hémodynamique, l’utilisation des indices hémodynamiques pour la réalisation d’une expansion volémique, la place des vasopresseurs et des inotropes.

BACKGROUND AND PURPOSE:The optimal anesthetic regimen for the endovascular treatment (EVT) of stroke due to large-vessel occlusion remains unclear. Patients with large infarct cores on initial imaging constitute a specific subpopulation. The aim of this study was to investigate the impact of the anesthesia type during EVT on outcomes in this subpopulation. MATERIALS AND METHODS:Data were extracted from the multicenter, randomized, controlled LASTE trial (n = 30 centers in France and Spain) that compared EVT plus best medical treatment versus best medical treatment alone in patients with a large infarct core (ASPECTS = 0-5). In this post hoc analysis, only patients who underwent EVT were included. We defined 2 study groups: general anesthesia (GA) and conscious sedation and/or local anesthesia (CS-LA). The primary end point was the functional outcome, assessed with the mRS at 3 months. Secondary end points included early neurologic status, infarct extension at day 1, symptomatic intracranial hemorrhage, and mortality. End points were investigated using univariate and multivariate analyses adjusted for prespecified confounders. RESULTS:For this post hoc analysis, we included 159 patients: 45 in the GA group and 114 in the CS-LA group. The functional outcome at 3 months was not different between groups: median mRS score = 5; interquartile range [IQR]: 3-6 in the GA group and 4; IQR: 3-6 in the CS-LA group (adjusted OR =0 .78; 95% CI, 0.52-1.18). However, in the GA group, the NIHSS score significantly worsened between admission and day 1 (mean difference = -3.8 [-6.6 to -1.0]; P = .007), infarct volume extension was more severe (mean difference: -26.5 mL [-50.2 to -2.9]; P = .028), and parenchymal hematoma was more frequently detected. Between-group differences in early neurologic improvement, symptomatic intracranial hemorrhage, and mortality were not significant. CONCLUSIONS:In this post hoc analysis of the LASTE trial data, we detected potential signals of a GA detrimental effect in patients with large infarct cores on baseline imaging. Larger studies are necessary to confirm this finding.

Linezolid is an alternative to vancomycin for treating Gram-positive central nervous system (CNS) healthcare-associated infections, but its optimal dosing remains debated. The PK-Pop-LCR prospective population pharmacokinetic/pharmacodynamic (PK/PD) study included acute brain injured (ABI) patients with an external ventricular drainage (EVD) receiving linezolid. A population PK model developed using plasma and cerebrospinal fluid (CSF) data, and Monte Carlo simulations calculated the probability of target attainment (PTA) and cumulative fraction of response (CFR) in CSF against methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant Staphylococcus epidermidis (MRSE). PD targets for CSF were AUC/MIC > 70 and 100% T> MIC. Toxicity thresholds (plasma Cmin,ss > 7 mg/L and AUCss > 300mg.h/L) was also assessed. CNS infections were confirmed in 14 of 25 patients included. Median AUCCSF/unbound AUCplasma ratio was around 80% for all patients despite higher CSF cytokines levels in CNS-infected patients. EVD flow rate influenced linezolid CSF exposure. For AUCCSF/MIC, 1200 mg/24h allowed to reach PTAs ≥90% only for MICs<1 mg/L, and CFR of 11.2% (MRSA) and 67.0% (MRSE). For T>MIC, 1200mg by continuous infusion (CI) would achieve CFR>95% for MRSE, while 2400mg (CI) would be needed for MRSA (PTA>90% for MIC=4mg/L; CFR = 95%) but with around 40% toxicity risk. We confirmed the extensive CSF distribution of linezolid. Higher doses (2400mg CI) may be considered for probabilistic treatment of CNS infection in ABI patients, despite CSF PK/PD targets further investigated. Early individualized dose adjustment based on MIC and drug monitoring is essential to balance efficacy and safety.

Preoperative survival prognostication is the main factor to consider when selecting patients who will benefit from metastatic spine surgery. Since patients’ selection for surgery is not fully standardized, we aim to identify clinical, oncological and biological markers associated with poor post-operative prognosis. A retrospective analysis was conducted in 105 patients referred to a specialized center for surgery of spinal metastasis between October 2020 and January 2022. Detailed clinical and biological variables were collected. Univariate and multivariate analyses were performed to assess overall survival. Among the 105 patients included, One-third died within six months. Multivariate survival analysis identified age, Karnofsky score, hyperalgesia and C-reactive protein (CRP) as independently associated with shorter survival. Patients with CRP values above 100 mg/L had a 57

INTRODUCTION:Subarachnoid haemorrhage (SAH) is relatively frequent, accounting for 5% of strokes and affects a young population. Arterial vasospasm is a frequent complication of SAH, with an estimated incidence as high as 70%. Vasospasm is responsible for cerebral ischaemia which in turn is potentially responsible for severe morbidity (neurological deficit, neuropsychiatric disorders), poor quality of life (institutionalisation, inability to return to work) and increased mortality. Treatment with intravenous milrinone, an arterial vasodilator, has been proposed, but no randomised controlled study exists. We hypothesised that an intravenous infusion of milrinone would improve the neurological recovery of patients with vasospasm following aneurysmal SAH at 3 months. METHODS AND ANALYSIS:The MiVAR (Milrinone Infusion for VAsospam treatment in subarachnoid hemoRrhage) study is an investigator-initiated, phase III multicentre, randomised placebo-controlled, double-blinded, superiority trial evaluating the effect of intravenous milrinone versus placebo (saline), in patients with cerebral vasospasm following aneurysmal SAH. Patients will be included within 6 hours of the confirmation of vasospasm diagnosis by a CT angiography and randomised to receive either milrinone (initial bolus of 0.1 mg/kg over 30 min-max 10 mg-followed by a continuous infusion at 1 µg/kg/min rate for at least 48 hours) or placebo. Milrinone (or placebo) could be increased to 1.5 µg/kg/min. The dose is adapted according to the clinical and/or transcranial Doppler response. 360 patients are expected to be included. The primary endpoint is the proportion of patients with a good neurological outcome at 3 months, defined as a modified Rankin score ≤2, obtained through a centralised standardised telephone interview (done by a unique trained team). The study started in August 2020, and the expected final follow-up is the last quarter of 2025. Analyses of the intention-to-treat and per-protocol populations are planned. ETHICS AND DISSEMINATION:The MiVAR trial protocol has been approved by an ethics committee (Comité de Protection des Personnes Ouest V), by the Agence Nationale de Sécurité du Médicament (ANSM, Number 160 828A-21, approval date 26 December 2019) and by the 'Commission Nationale Informatique et Liberté' (CNIL, decision DR-2020-076, approval date 21 February 2020). The study will be conducted according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. The MiVAR study will be the first multicentre randomised study to evaluate the efficacy of intravenous milrinone in improving the neurological outcomes at 3 months in patients with vasospasm following aneurysmal SAH. TRIAL REGISTRATION NUMBERS:NCT04362527, EudractCT number 2019-002145-37.

OBJECTIVE:To develop a multidisciplinary French framework addressing neurosurgical management in the initial phase of traumatic brain injury (TBI) in adults and children. DESIGN:A panel of 29 experts was formed at the request of the French Society of Neurosurgery (SFNC), with the participation of the French Society of Pediatric Neurosurgery (SFNCP), French Society of Private-Practice Neurosurgeons (SFNCL), French-Speaking Neurocritical Care and Neuro-Anesthesiology Society (ANARLF), French Society of Anesthesia, Critical Care and Perioperative Medicine (SFAR), French-Speaking Pediatric Emergency and Intensive Care Group (GFRUP), French Society of Neuroradiology (SFNR), French-Speaking Infectious Diseases Society (SPILF), and the French Society of Physical Medicine and Rehabilitation (SOFMER). METHODS:Questions were formulated using the PICO (Patients, Intervention, Comparison, Outcome) format, grouped into 7 categories: 1. Factors of poor prognosis, 2. Extradural hematoma, 3. Acute subdural hematoma, 4. Skull-base fracture and dural tear, 5. Penetrating traumatic brain injury, 6. Post-traumatic cerebrospinal fluid disorder, and 7. Pediatric specificities. RESULTS:Synthesis by the experts and application of the GRADE® method resulted in the formulation of 45 recommendations. Strong consensus was reached for all recommendations at the first round of rating, CONCLUSION: There was a strong consensus among the experts on important interdisciplinary recommendations to improve the neurosurgical management of patients with TBI.

The systematic collection of longitudinal data is very common in practice, making mixed models widely used. Most developments around these models focus on modeling the mean trajectory of repeated measurements, typically under the assumption of homoskedasticity. However, as data become increasingly rich through intensive collection over time, these models can become limiting and may introduce biases in analysis. In fact, such data are often heterogeneous, with the presence of outliers, heteroskedasticity, and asymmetry in the distribution of individual measurements. Therefore, ignoring these characteristics can lead to biased modeling results. In this work, we propose a mixed-effect distributional regression model based on the asymmetric Laplace distribution to: (1) address the presence of outliers, heteroskedasticity, and asymmetry in longitudinal measurements; (2) model the entire individual distribution of the heterogeneous longitudinal response over time, rather than just its conditional expectation; and (3) give a more comprehensive evaluation of the impact of covariates on the distribution of the responses through meaningful indicator. A Bayesian estimation procedure is presented. In order to choose between two distributional regression models, we also propose a new model selection criterion for longitudinal data. It measures the proximity between the individual distribution estimated by the model and the empirical individual distribution of the data over time, using a set of quantiles. The estimation procedure and the selection criterion are validated in a simulation study and the proposed model is compared to a distributional regression mixed model based on the Gaussian distribution and a location-scale linear quantile mixed model. Finally, the proposed model is applied to analyze blood pressure over time for hospitalized patients in the intensive care unit.

Delayed cerebral ischemia associated with cerebral vasospasm (CVS) in aneurysmal subarachnoid hemorrhage significantly affects patient prognosis. Levosimendan has emerged as a potential treatment, but clinical data are lacking. The aim of this study is to decipher levosimendan’s effect on cerebral hemodynamics by automated quantitative measurements of brain computed tomography perfusion (CTP). We conducted a retrospective analysis of a database of a neurosurgical intensive care unit. All patients admitted from January 2018 to July 2022 for aneurysmal subarachnoid hemorrhage and treated with levosimendan for CVS who did not respond to other therapies were included. Quantitative measurements of time to maximum (Tmax), relative cerebral blood volume (rCBV), and relative cerebral blood flow (rCBF) were automatically compared with coregistered CTP before and after levosimendan administration in oligemic regions. Of 21 patients included, CTP analysis could be performed in 16. Levosimendan improved Tmax from 14.4 s (interquartile range [IQR] 9.1–21) before treatment to 7.1 s (IQR 5.5–8.1) after treatment (p < 0.001). rCBV (94

Augmented renal clearance (ARC) is an increase in the measured creatinine clearance (CLCR), the cause of which remains poorly understood. ARC may be associated with drug underdosing and appears to be more frequent in patients with brain damage, such as subarachnoid hemorrhage (SaH), although the incidence of ARC remains poorly understood. The aim of this study was to investigate the prevalence of ARC in patients with SaH in a neurointensive care unit (neuro-ICU) and to identify factors associated with ARC. All consecutive patients hospitalized in the neuro-ICU of Bordeaux University Hospital between June 2018 and June 2019 for SaH treatment were retrospectively included. CLCR was measured daily via 24-h urine collection. ARC was defined as a CLCR ≥ 130 mL/min/1.73 m2. The effects of different covariates on the time course of CLCR were investigated using a linear mixed model. Of the 205 included study participants, 168 developed ARC during their neuro-ICU stay; the estimated ARC prevalence was 82

Le médecin anesthésiste-réanimateur est fréquemment confronté à la prise en charge de patients septiques, que ce soit au bloc opératoire, en réanimation ou les deux. Il existe de solides recommandations sur la prise en charge globale de ces patients notamment avec des principes bien établis de réanimation : administration rapide d’un anti-infectieux, remplissage par cristalloïdes, si nécessaire support vasopresseur par noradrénaline. En plus de cette prise en charge bien codifiée, le protocole d’anesthésie doit être adapté à cette typologie de patients. L’induction anesthésique, souvent réalisée en séquence rapide privilégiera la kétamine comme hypnotique du fait de bonnes conditions d’expositions pour l’intubation et une bonne tolérance hémodynamique, sans complications. Le curare de prédilection est la succinylcholine en l’absence de contre-indication. De plus, afin de guider au mieux la prise en charge, il convient d’utiliser un monitorage invasif, au moins à l’aide d’un cathéter artériel et idéalement couplé à un monitorage du débit cardiaque. Le dosage de la lactatémie permet également de guider la prise en charge contrairement à celui de la SvO2. Enfin, le continuum de prise en charge entre le bloc opératoire et la réanimation est primordial et fait appel à l’ensemble des compétences des médecins anesthésistes-réanimateurs.

Stroke is strongly associated with high blood pressure (hypertension). Treatment of hypertension must be considered before, during and after the occurrence of an acute event, with therapeutic objectives varying according to the type of stroke and/or other strategies implemented. A new entity, blood pressure variability (BPV), is emerging in the literature and is likely to be an additional therapeutic target in the future.

Les accidents vasculaires cérébraux (AVC) sont très liés à l’hypertension artérielle (HTA). Le traitement de l’HTA doit être envisagé avant, pendant et après la survenue d’un évènement aigu, les objectifs thérapeutiques variant en fonction du type d’AVC et/ou des autres stratégies mises en œuvre. Une nouvelle entité, qui est la variabilité de la pression artérielle (VPA), émerge dans la littérature et sera probablement une cible thérapeutique supplémentaire à l’avenir.

PurposeTo provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patientsDesignA consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d’Études sur l’Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence.MethodsFour fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology.ResultsThe SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as “Professional Practice Recommendations” (PPR) rather than “Formalized Expert Recommendations”. After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions.ConclusionsStrong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.

Objective: Most brain biopsies are performed using the frame-based stereotactic technique and several studies describe the time taken and rate of complications, often allowing an early discharge. In comparison, neuronavigation-assisted biopsies are performed under general anesthesia and their complications have been poorly described. We examined the complication rate and determined which patients will worsen clinically. Methods: All adults who underwent a neuronavigation-assisted brain biopsy for a supratentorial lesion from Jan, 2015, to Jan, 2021, in the Neurosurgical Department of the University Hospital Center of Bordeaux, France, were analyzed retrospectively in accordance with the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement. The primary outcome of interest was short-term (7 days) clinical deterio-ration. The secondary outcome of interest was the complication rate. Results: The study included 240 patients. The median postoperative Glasgow score was 15. Thirty patients (12.6 %) showed acute postoperative clinical worsening, including 14 (5.8 %) with permanent neurological worsening. The median delay was 22 h after the intervention. We examined several clinical combinations that allowed early postoperative discharge. A preoperative Glasgow prognostic score of 15, Charlson Comorbidity Index <= 3, preoperative World Health Organization Performance Status <= 1, and no preoperative anticoagulation or anti-platelet treatment predicted postoperative worsening (negative predictive value, 96.3 %). Conclusion: Optical neuronavigation-assisted brain biopsies might require longer postoperative observation than frame-based biopsies. Based on strict preoperative clinical criteria, we consider to plan postoperative observation for 24 h a sufficient hospital stay for patients who undergo these brain biopsies.

Background Cardiac complications due to non-traumatic subarachnoid hemorrhage (SAH) are usually described using classical echocardiographic evaluation. Strain imaging appears to have better sensitivity than standard echocardiographic markers for the diagnosis of left ventricular dysfunction. The aim of this study was to determine the prevalence of cardiac dysfunction defined as a Global Longitudinal Strain (GLS) ≥ − 20% in patients with good-grade SAH (WFNS 1 or 2). Methods Seventy-six patients with good-grade SAH were prospectively enrolled and analyzed at admission for neurocritical care. Transthoracic echocardiography was performed on days 1, 3, and 7 after hemorrhage. Routine measurements, including left ventricular ejection fraction (LVEF), were performed, and off-line analysis was performed by a blinded examiner, to determine 2-, 3-, and 4-cavity longitudinal strain and left ventricular GLS. GLS was considered altered if it was ≥ − 20%, we also interested the value of ≥ − 17%. LVEF was considered altered if it was < 50%. Results On day 1, 60.6% of patients had GLS ≥ − 20% and 21.2% of patient had GLS ≥ − 17%. In comparison, alteration of LVEF was present in only 1.7% of patients. The concordance rate between LVEF < 50% and GLS ≥ − 20% and LVEF ≥ 50% and GLS < − 20% was 46%. Conclusion Strain imaging showed a higher prevalence (60.6%) of left ventricular dysfunction during the acute phase of good-grade SAH (WFNS 1 or 2) than previously described.

Abstract Background Analgesia Nociception Index (ANI) is a device based on analysis of the R-R interval and respiratory sinus arrhythmia to assess the balance between sympathetic and parasympathetic activity. The autonomic system is directly affected by load changes. Therefore, monitoring sympathetic tone and its change could theoretically allow tracking of load changes during volume expansion. The aim of the present study was to determine whether changes in ANI are able to track the increase in stroke volume caused by volume expansion (SV). Methods This prospective observational study included mechanically ventilated patients undergoing neurosurgery and benefiting from SV monitoring. Exclusion criteria were cardiac dysfunction, arrhythmias, beta-blockade therapy, and dysautonomia. SV was optimized by fluid administration of 250 ml of crystalloid fluid. A positive fluid increase was defined as a SV increase of 10% or more from baseline. Changes in SV and medium ANI (ANIm) were recorded before and 4 to 5 min after volume expansion. Results Sixty-nine patients had 104 fluid challenges (36 positive and 68 negative). Volume expansion resulted in a greater ANI increase in responders than in nonresponders. The change in ANIm > 5 predicted fluid responsiveness with a sensitivity of 68.4% (95% CI: 67.4% to 69.5%) and a specificity of 51.2% (95% CI: 50.1% to 52.3%). The area under the receiver operating characteristic curve was 0.546 (95% CI: 0.544 to 0.549) and appeared to be affected by remifentanil dose and baseline ANI. Conclusion Changes in ANIm induced by fluid challenge is not able to predict fluid responsiveness in mechanically ventilated patients undergoing neurosurgery. Trial registration Clinical trial registration: NCT04223414.

We aimed to develop and validate a Portuguese version of the Obstetric Quality of Recovery-10 (ObsQoR-10-Portuguese) patient-reported outcome measure and evaluate its psychometric properties.After ethical approval, we recruited term pregnant women undergoing uncomplicated elective cesarean delivery in a single Brazilian institution. Women were invited to complete the translated ObsQoR-10-Portuguese and EuroQoL (EQ-5D) questionnaires (including a global health visual analog scale [GHVAS]) at 24 h (±6 h) following delivery, and a subset of women an hour later. We assessed validity and reliability of ObsQoR-10-Portuguese.One hundred thirteen enrolled women completed the surveys at 24 h and 29 women at 25 h (100% response rate). Validity: (i) convergent validity: ObsQoR-10-Portuguese correlated moderately with EuroQoL score (r = −0.587) and GHVAS score (r = 0.568) at 24 h. (ii) Discriminant validity: ObsQoR-10 discriminated well between good versus poor recovery (GHVAS score ≥ 70 versus < 70; difference in mean scores 14.2; p < 0.001). (iii) Hypothesis testing: 24-h ObsQoR-10-Portuguese scores correlated with gestational age (r = 0.191; p = 0.043). (iv) Cross-cultural validity: differential item functioning analysis suggested bias in 2 items. Reliability: (i) internal consistency was good (Cronbach’s alpha = 0.82 and inter-item correlation = 0.31). (ii) Split-half reliability was very good (Spearman–Brown Prophesy Reliability Estimate = 0.80). (iii) Test re-test reliability was excellent (intra-class correlation coefficient = 0.87). (iv) Floor and ceiling effects: < 5% women scored either 0 or 100 (lowest and highest scores, respectively).ObsQoR-10-Portuguese is valid and reliable, and should be considered for use in Portuguese-speaking women to assess their quality of inpatient recovery following cesarean delivery.