BACKGROUND:Intraoperative continuous renal replacement therapy (IoCRRT) represents a viable approach for managing the hemodynamic and metabolic challenges encountered during liver transplantation (LT), particularly in high-acuity patients. Our objective was to evaluate the impact of IoCRRT in comparison with conservative treatment on liver graft function during the immediate post-transplant period. METHODS:This retrospective, bicentric cohort study included patients who underwent LT between January 2014 and December 2019. Propensity score matching was conducted to mitigate disparities between the IoCRRT and control groups. Comparative analysis of post-transplant outcomes encompassed early allograft dysfunction (EAD), as defined by Olthoff, along with quantitative evaluation using the Model for Early Allograft Function (MEAF) scoring. RESULTS:The analysis included 73 patients in both groups, demonstrating comparability, with a mean MELD score of 31.5 ± 9.4 in the IoCRRT group compared to 30.6 ± 9.6 (SMD, Standardized mean difference = 0.088) in the control group. The overall frequency of EAD was 32.9% in the IoCRRT group and 43.8% in the control group (P = .243), with quantitative assessment using the MEAF score yielding 6.81 versus 6.89 (P = .843), respectively. No significant differences were observed in the length of stay in the intensive care unit or 90-day mortality. CONCLUSIONS:Implementation of IoCRRT during LT did not correlate with a reduction in the occurrence or severity of early allograft dysfunction.

BACKGROUND:The difference between arterial and central venous carbon dioxide partial pressure (PCO2 gap), a marker of oxygen delivery (DO2) and oxygen consumption (VO2) adequacy, has been evaluated as a promising prognostic tool in intensive care unit (ICU) patients. We therefore sought to study the association between intraoperative PCO2 gap and postoperative complications (POC) in the perioperative setting of elective major abdominal surgery. METHODS:We conducted a single-centre prospective observational study. All adult patients who underwent major planned abdominal surgery were eligible. PCO2 gap was measured every 2 h during surgery, at ICU admission and repeated 12 h and 24 h later. Severe POC within 28 days after surgery were defined as complications graded 3 or more according to Clavien-Dindo classification. Following a univariate analysis, a multivariable analysis using a logistic regression model was performed. RESULTS:Ninety patients were included and divided into two groups according to the occurrence of POC. No significant difference was found between groups regarding baseline characteristics at inclusion. Thirty-nine (43%) patients developed postoperative complications. The median [IQR] intraoperative PCO2 gap was significantly higher in patients who had complications (6.5 [5.5-7.3] mmHg) compared to those who did not (5.0 [3.9-5.8] mmHg; p < 0.001). The area under the receiver operating characteristic curve for occurrence of POC was 0.78 for the PCO2 gap. After multivariable analysis, PCO2 gap was found independently associated with POC (OR: 14.9, 95% CI [4.68-60.1], p < 0.001) with a threshold value of 6.2 mmHg. The duration of surgery (OR: 1.01, 95% CI [1.00; 1.01], p = 0.04) and the need for vasoactive support during surgery (OR: 5.76, 95% CI [1.72; 24.1], p = 0.006) were also independently associated with POC. CONCLUSION:Intraoperative PCO2 gap is a relevant predictive factor of severe postoperative complications in high-risk elective surgery patients. TRIAL REGISTRATION:ClinicalTrials.gov, NCT03914976.

Introduction: Liver failure is associated with hepatic and extrahepatic organ failure leading to a high short-term mortality rate. Extracorporeal albumin dialysis (ECAD) aims to reduce albumin-bound toxins accumulated during liver failure. ECAD detoxifies blood using albumin dialysis through an artificial semipermeable membrane with recirculation (molecular adsorbent recirculating system, MARS) or without (single-pass albumin dialysis, SPAD). Methods: We performed a randomized crossover open trial in a surgical intensive care unit. The primary outcome of the study was total bilirubin reduction during MARS and during SPAD therapies. The secondary outcomes were conjugated bilirubin and bile acid level reduction during MARS and SPAD sessions and tolerance of dialysis system devices. Inclusion criteria were adult patients presenting liver failure with factor V activity <50% associated with bilirubin ≥250 μmol/L and a complication (either hepatic encephalopathy, severe pruritus, or hepatorenal syndrome). For MARS and SPAD, the dialysis flow rate was equal to 1,000 mL/h. Results: Twenty crossovers have been performed. Baseline biochemical characteristics (bilirubin, ammonia, bile acids, creatinine, and urea) were not statistically different between MARS and SPAD. Both ECAD have led to a significant reduction in total bilirubin (−83 ± 67 μmol/L after MARS; −122 ± 118 μmol/L after SPAD session), conjugated bilirubin (−82 ± 61 μmol/L after MARS; −105 ± 96 μmol/L after SPAD session), and bile acid levels (−64 ± 75 μmol/L after MARS; −56 ± 56 μmol/L after SPAD session), all nondifferent comparing MARS to SPAD. Conclusion: A simple-to-perform SPAD therapy with equal to MARS dialysate flow parameters provides the same efficacy in bilirubin and bile acid removal. However, clinically relevant endpoints have to be evaluated in randomized trials to compare MARS and SPAD therapies and to define the place of SPAD in the liver failure care program.

BACKGROUND:Hypotension prediction index (HPI) software is a proprietary machine learning-based algorithm used to predict intraoperative hypotension (IOH). HPI has shown superiority in predicting IOH when compared to the predictive value of changes in mean arterial pressure (ΔMAP) alone. However, the predictive value of ΔMAP alone, with no reference to the absolute level of MAP, is counterintuitive and poor at predicting IOH. A simple linear extrapolation of mean arterial pressure (LepMAP) is closer to the clinical approach.OBJECTIVES:Our primary objective was to investigate whether LepMAP better predicts IOH than ΔMAP alone.DESIGN:Retrospective diagnostic accuracy study.SETTING:Two tertiary University Hospitals between May 2019 and December 2019.PATIENTS:A total of 83 adult patients undergoing high risk non-cardiac surgery.DATA SOURCES:Arterial pressure data were automatically extracted from the anaesthesia data collection software (one value per minute). IOH was defined as MAP < 65 mmHg.ANALYSIS:Correlations for repeated measurements and the area under the curve (AUC) from receiver operating characteristics (ROC) were determined for the ability of LepMAP and ΔMAP to predict IOH at 1, 2 and 5 min before its occurrence (A-analysis, using the whole dataset). Data were also analysed after exclusion of MAP values between 65 and 75 mmHg (B-analysis).RESULTS:A total of 24 318 segments of ten minutes duration were analysed. In the A-analysis, ROC AUCs to predict IOH at 1, 2 and 5 min before its occurrence by LepMAP were 0.87 (95% confidence interval, CI, 0.86 to 0.88), 0.81 (95% CI, 0.79 to 0.83) and 0.69 (95% CI, 0.66 to 0.71) and for ΔMAP alone 0.59 (95% CI, 0.57 to 0.62), 0.61 (95% CI, 0.59 to 0.64), 0.57 (95% CI, 0.54 to 0.69), respectively. In the B analysis for LepMAP these were 0.97 (95% CI, 0.9 to 0.98), 0.93 (95% CI, 0.92 to 0.95) and 0.86 (95% CI, 0.84 to 0.88), respectively, and for ΔMAP alone 0.59 (95% CI, 0.53 to 0.58), 0.56 (95% CI, 0.54 to 0.59), 0.54 (95% CI, 0.51 to 0.57), respectively. LepMAP ROC AUCs were significantly higher than ΔMAP ROC AUCs in all cases.CONCLUSIONS:LepMAP provides reliable real-time and continuous prediction of IOH 1 and 2 min before its occurrence. LepMAP offers better discrimination than ΔMAP at 1, 2 and 5 min before its occurrence. Future studies evaluating machine learning algorithms to predict IOH should be compared with LepMAP rather than ΔMAP.

Background The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Few studies have assessed their clinical impact. The aim of this monocentric study was to assess the impact of those guidelines on outcomes after liver surgery with a special focus on cirrhotic patients. Method Postoperative outcomes of patients undergoing hepatectomy 30 months before and after ERAS implementation according to the 2016 ERAS guidelines were compared after inverse probability of treatment weighting (IPTW). Primary endpoint was 90-day morbidity. Results From 2015 to 2020, 430 patients underwent hepatectomy including 226 procedures performed before and 204 after ERAS implementation. After IPTW, overall morbidity (42.5% vs. 64.7%, p < 0.001), Comprehensive Complication Index (CCI) score (14.3 vs. 20.8, p = 0.004), length of stay (10.4 vs. 13.7 days, p = 0.001) and textbook outcome (50% vs. 40.2%, p = 0.022) were significantly improved in the ERAS group, while mortality and severe complications were similar in both groups. In the non-cirrhosis subgroup (n = 321), these results were confirmed. However, in the cirrhosis subgroup (n = 105), no difference appeared on outcomes after hepatectomy with an overall morbidity (47.5% vs. 65.2%, p = 0.069) and a length of stay (8 vs. 9 days, p = 0.310) which were not significantly different. The compliance rate to ERAS guidelines was 60% in both cirrhotic and non-cirrhotic subgroups. Conclusion Perioperative ERAS program for hepatectomy results in improved outcomes with decreased rate of non-severe morbidity. Although those guidelines are not deleterious for cirrhotic patients, they probably require revisions to be more effective in this patient population.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have led to massive admissions to intensive care units (ICUs). An ultrasound examination of the thorax is widely performed on admission in these patients. The primary objective of our study was to assess the performance of the lung ultrasound score (LUS) on ICU admission to predict the 28-day mortality rate in patients with SARS-CoV-2. The secondary objective was to asses the performance of thoracic ultrasound and biological markers of cardiac injury to predict mortality. This multicentre, retrospective, observational study was conducted in six ICUs of four university hospitals in France from 15 March to 3 May 2020. Patients admitted to ICUs because of SARS-CoV-2-related acute respiratory failure and those who received an LUS examination at admission were included. The area under the receiver-operating characteristics (ROC) curve was determined for the LUS score to predict the 28-day mortality rate. The same analysis was performed for the Simplified Acute Physiology Score, left ventricular ejection fraction, cardiac output, brain natriuretic peptide and ultra-sensitive troponin levels at admission. In 57 patients, the 28-day mortality rate was 21%. The area under the ROC curve of the LUS score value on ICU admission was 0.68 [95% CI 0.54–0.82; p = 0.05]. In non-intubated patients on ICU admission (n = 40), the area under the ROC curves was 0.84 [95% CI 0.70–0.97; p = 0.005]. The best cut-off of 22 corresponded to 85% specificity and 83% sensitivity. LUS scores on ICU admission for SARS-CoV-2 did not efficiently predict the 28-day mortality rate. Performance was better for non-intubated patients at admission. Performance of biological cardiac markers may be equivalent to the LUS score.

in order to keep airways open, a PEEP of 7 cmH2O was appropriate in patients with healthy lungs and a normal BMI. However, this hypothesis remains unclear in patients undergoing robotic gynaecologic surgery. All points considered, a PEEP of 8 cmH2O, applied to a low tidal volume ventilation strategy in robotic gynaecologic surgical patients, is thought to have no benefit compared with 4 cmH2O with respect to intrapulmonary shunt.

BACKGROUND:Although liver transplantation (LT) improves survival in cirrhotic patients with hepatopulmonary syndrome (HPS), few data exist concerning post-operative complications in these patients.OBJECTIVE:To compare complications after LT between patients with and without HPS.METHODS:In a case-control study, we retrospectively analyzed all patients who underwent LT in our center from January 2010 to July 2016. We compared cases of identified HPS to controls matched for age, MELD score, comorbidities, red blood cells transfused, and highest dosage of norepinephrine perfused during transplantation.RESULTS:Among 451 transplanted patients, we identified 71 patients with HPS who could be analyzed. We found a significantly (p<0.001) higher number of post-operative complications in patients with HPS (median 5 vs 3), with more occurrence of cardiac, infectious and surgical complications than in the controls: 39.4% vs 12.7% (p<0.001), 81.7% vs 49.3% (p<0.001), and 59.2% vs 40.1% (p<0.029), respectively. There were also more ICU readmissions at 1 month among HPS patients (10 vs 1, p=0.01). There was no significant difference concerning ventilation data, lengths of ICU or hospital stay (8.5 [range 3-232] and 32 [14-276] days, respectively on the whole cohort) and death in the ICU (4.2% on the whole cohort). The 1-year survival was higher in HPS patients (94.4% vs 81.1%, p=0.034); there was no difference in 5-year survival.CONCLUSION:HPS patients seem to have a higher number of complications in the first month following LT.

BACKGROUND: Hepatic surgery is a major abdominal surgery. Epidural analgesia may decrease the incidence of postoperative morbidities. Hemostatic disorders frequently occur after hepatic resection. Insertion or withdrawal (whether accidental or not) of an epidural catheter during coagulopathic state may cause an epidural hematoma. The aim of the study is to determine the incidence of coagulopathy after hepatectomy, interfering with epidural catheter removal, and to identify the risk factors related to coagulopathy. METHODS: We performed a retrospective review of a prospective, multicenter, observational database including patients over 18 years old with a history of liver resection. Main collected data were the following: age, preexisting cirrhosis, Child-Pugh class, preoperative and postoperative coagulation profiles, extent of liver resection, blood loss, blood products transfused during surgery. International normalized ratio (INR) ≥1.5 and/or platelet count <80,000/mm3 defined coagulopathy according to the neuraxial anesthesia guidelines. A logistic regression analysis was performed to assess the association between selected factors and a coagulopathic state after hepatic resection. RESULTS: One thousand three hundred seventy-one patients were assessed. Seven hundred fifty-nine patients had data available about postoperative coagulopathy, which was observed in 53.5% [95% confidence interval, 50.0–57.1]. Maximum derangement in INR occurred on the first postoperative day, and platelet count reached a trough peak on postoperative days 2 and 3. In the multivariable analysis, preexisting hepatic cirrhosis (odds ratio [OR] = 2.49 [1.38–4.51]; P = .003), preoperative INR ≥1.3 (OR = 2.39 [1.10–5.17]; P = .027), preoperative platelet count <150 G/L (OR = 3.03 [1.77–5.20]; P = .004), major hepatectomy (OR = 2.96 [2.07–4.23]; P < .001), and estimated intraoperative blood loss ≥1000 mL (OR = 1.85 [1.08–3.18]; P = .025) were associated with postoperative coagulopathy. CONCLUSIONS: Coagulopathy is frequent (53.5% [95% confidence interval, 50.0–57.1]) after liver resection. Epidural analgesia seems safe in patients undergoing minor hepatic resection without preexisting hepatic cirrhosis, showing a normal preoperative INR and platelet count.

We here report the case of successful orthotopic liver transplantation (LT) following acute liver failure (ALF) related to sinusoidal obstruction syndrome (SOS). This syndrome is one of the main causes of death early after bone marrow transplantation (BMT); LT seems to be an effective treatment of the most severe forms of SOS but no official recommendation exist about this subject. With this clinical case we would like to show that after careful patient selection and appropriate timing, LT for treatment of severe SOS is safe and effective.

Introduction: The peroperative management of liver transplantation is still associated with many cardiocirculatory complications in which diastolic dysfunction may play a contributive role. Transoesophageal echocardiography is a monitoring device commonly used in liver transplantation allowing diastolic function assessment. Methods: We prospectively analysed the peroperative transoesophageal echocardiography recordings of 40 patients undergoing liver transplantation in order to describe changes in diastolic function at different steps of the surgery. The diastolic function marker we used was the lateral mitral annulus motion (E' wave velocity) obtained by tissue-Doppler imaging. In addition, we also studied the left ventricular filling pressure indices and systolic function. Results: As a whole, there was no global change in E' wave velocity throughout the surgery. However, 11 patients (27.5%) presented a decrease in E' wave velocity up to 15% that identified an occurrence of diastolic function alteration. In this group, other peroperative data were not different from other patients (amount of bleeding, fluid administration or vasopressive support). Conversely, this group experienced lower preoperative E' wave velocity values (9 cm.s (1) versus 12 cm.s (1), P = 0.05) and an increased incidence of postoperative cardiorespiratory complications (OR = 6 [1-56], P = 0.02). Considering all patients, 18 patients had an E' wave velocity under 10 cm.s (1) at unclamping, characterizing a diastolic dysfunction according to the usual criteria. This dysfunction was not associated with cardiorespiratory complications. Conclusion: This work investigated peroperative systematic echocardiographic evaluation of diastolic function during liver transplantation. Diastolic dysfunction occurs frequently during liver transplantation and could lead to postoperative cardiorespiratory complications. (C) 2017 Societe francaise d'anesthesie et de reanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.

La ventilation protectrice associant un volume courant bas, une pression positive en fin d’expiration (PEEP) et des manœuvres de recrutement améliore le pronostic postopératoire au décours de la chirurgie abdominale [1]. Cependant, en chirurgie hépatique, la PEEP pourrait être associée à une augmentation des pertes sanguines peropératoires. L’objectif de ce travail était de décrire les modalités de ventilation peropératoire et leur impact sur les pertes sanguines estimées (PSE) au décours de chirurgie de résection hépatique. Un observatoire chirurgical multicentrique français incluant les données périopératoires des hépatectomies a été mis en place depuis 2012 dans le cadre du PHRC national AOM11060. Ce travail a mené une analyse rétrospective des données peropératoires recueillies prospectivement lors des hépatectomies réalisées entre 2012 et février 2015 dans quatre centres de chirurgie hépatique. Les données suivantes ont été analysées : âge, sexe, IMC, cirrhose, hépatectomie majeure (≥ 3 segments), cœlioscopie, clampage vasculaire, durée de la chirurgie, PEEP et volume courant post-induction, pertes sanguines estimées, fréquence et volume de transfusion de culots globulaires (CG), de plasma frais congelé (PFC), durée de séjour hospitalier et mortalité à j90. Les résultats sont exprimés en nombre (pourcentage) ou médiane [interquartiles], les patients ayant une PEEP ≥ 5 cm H2O (PEEP haute) comparés aux patients ayant bénéficié d’une PEEP < 5 (PEEP basse) grâce aux tests exact de Fischer et Mann Whitney. Mille et quatre-vingt-dix-neuf patients âgés de 58 [44–67] ans (57 % hommes) ont été analysés après 39 % d’hépatectomie majeure, 13 % de chirurgie cœlioscopique. La PEEP était ≥ 5 cm H2O pour 893 patients (PEEP médiane = 5 [5–6]) et < 5 cm H2O chez 206 patients (PEEP médiane = 4 [2–4]). Le volume courant médian post-induction était de 7 [6,5–8] mL/kg sans différence entre les deux groupes. De même, la durée de séjour hospitalier et la mortalité à j90 étaient respectivement de 9 [6–14] jours et de 1 % sans différence significative entre les deux groupes. Les données peropératoires sont présentées dans le Tableau 1. Ces données multicentriques françaises montrent que la ventilation peropératoire au cours des hépatectomies est de type protectrice dans plus de 80 % des cas. Par ailleurs, dans ce collectif important de résections hépatiques, l’application peropératoire d’une PEEP ≥ 5 cm H2O, comparée à PEEP < 5 n’était pas associée à une augmentation des PSE.

La chirurgie hépatique est une chirurgie abdominale majeure pour laquelle l'analgésie péridurale (APD) semble bénéfique en terme de morbidité postopératoire [1]. Cependant, une coagulopathie peut fréquemment survenir après hépatectomie [2]. La pose ou l'ablation (même accidentelle) d'un cathéter péridural dans un contexte de coagulopathie peut être préjudiciable car à risque d'hématome périmédullaire [3]. L'objectif de cette étude est d'identifier sur un grand échantillon de données, les facteurs prédictifs de survenue d'une coagulopathie incompatible avec la présence d'un cathéter péridural après hépatectomie. Il s'agit d'une analyse rétrospective d'une base de données constituée dans le cadre du PHRC national 2011 AOM11060 incluant les patients opérés d'une hépatectomie (clinicaltrials.gov NCT01715402). Les données recueillies sont : âge, sexe, existence d'une cirrhose, clairance du vert d'indocyanine (VIC), profil de coagulation préopératoire, étendue de l'hépatectomie (majeure si au moins 3 segments réséqués), embolisation ou thrombectomie, pertes sanguines, remplissage vasculaire, nombre de CGR transfusés en peropératoire, température en fin de bloc. La coagulopathie est définie par : TP < 50 % et/ou plaquettes < 80 G/L. Ces paramètres sont dosés en préopératoire, à j1 puis au moins une fois toutes les 48 heures jusqu'à j5. Nous avons testé les facteurs de risque potentiels de coagulopathie dans une analyse univariée puis par régression logistique multivariée. Mille trois cent soixante et onze patients inclus. Les caractéristiques démographiques, données pré- et peropératoires sont résumées dans le Tableau 1. En postopératoire, 29,8 % développent une coagulopathie dans les 5 jours. La Fig. 1 montre l'évolution du TP et des plaquettes. En analyse univariée, les facteurs prédictifs de coagulopathie sont : cirrhose sous-jacente (p = 0,0032), TP préopératoire abaissé (p < 0,0001 pour TP <75 % (VPN = 73 %)), plaquettes abaissées (p = 0,022 pour plaquettes <130 G/l (VPN = 74 %)), hépatectomie majeure (p < 0,0001), thrombectomie associée (p = 0,0087), pertes sanguines élevées (p < 0,0001 pour pertes >1000 ml [VPN = 74,7 %]). En analyse multivariée, les facteurs de risque indépendants sont : TP préopératoire abaissé (p = 0,0196), hépatectomie majeure (p = 0,0076). La coagulopathie post-hépatectomie est fréquente, identifiée dans 29,8 % des cas. Il existe peu de facteurs de risque indépendants dans notre étude : TP abaissé et hépatectomie majeure. Ceci permettrait d'élargir les indications d'APD pour les patients opérés d'une hépatectomie mineure avec TP préopératoire normal.

Le nouveau système d’attribution des greffons défini par l’Agence de la biomédecine et en vigueur depuis le 6 mars 2007 est basé sur le calcul d’un « score Foie » multicritères. Ceci permet l’accès à la transplantation hépatique (TH) à des patients présentant une cirrhose évoluée pouvant conduire à de multiples défaillances d’organes. Ainsi, certains patients bénéficient même d’une TH au décours d’épisodes de décompensation sévère nécessitant une hospitalisation en réanimation. Or, la TH chez ces patients à risque est plus à même d’induire des complications postopératoires graves potentiellement délétères pour le greffon voire pour la survie du patient. L’objectif de cette étude était d’évaluer la survenue de complications postopératoire graves après TH et de comparer leur incidence chez les patients Child C aux autres patients (Child A et B). Il s’agit d’une étude de cohorte rétrospective évaluant l’ensemble des patients ayant bénéficié d’une TH entre janvier 2011 et décembre 2012. Nous avons recueilli, au cours de la première année après TH, les complications postopératoires graves suivantes : reprise chirurgicale, infection, insuffisance rénale chronique (IRC) avec clairance de la créatinine inférieure à 60 mL/min, nécessité de dialyse au long cours, nécessité de réhospitalisation en réanimation et décès. Dans un deuxième temps, nous avons comparé la survenue de ces complications parmi les patients transplantés lors d’un séjour en réanimation aux autres patients Child C. Nous avons inclus 100 patients. La nécessité d’une reprise chirugicale, la survenue d’une infection, le développement d’une insuffisance rénale chronique étaient statistiquement plus fréquents dans chez les patients Child C (Tableau 1 et Fig. 1). Aucune différence statistique n’était retrouvée pour la dialyse chronique, la réhospitalisation en réanimation et la mortalité. Vingt-trois patients Child C (soit 36,5 % des patients Child C) ont été transplantés lors d’un séjour en réanimation. Ils ne présentaient pas, de manière statistiquement significative, plus de complications que les autres patients Child C. Nous n’avons pas mis en évidence de différence sur la mortalité. Ces résultats surprenants sont probablement en lien avec un effectif insuffisant. Il en va de même concernant la comparaison des patients transplantés depuis la réanimation aux autres patients Child C. L’incidence accrue des complications postopératoires chez les patients Child C nous paraît être un résultat cohérent au vu de la gravité de leur terrain pré-TH. En revanche, nous sommes interpellés par l’importance de l’incidence de l’IRC chez les patients Child C dans notre étude (41,2 %) par rapport aux données de la littérature (25 %). Ce résultat mériterait d’être l’objet d’une étude ultérieure.

Les complications cardio-vasculaires sont une des principales causes de morbi-mortalité post-transplantation hépatique (TH), les pathologies cardiaques et hépatiques étant étroitement liées. L'hypertension portale est responsable d'une dysfonction myocardique appelée cardiomyopathie du cirrhotique (CMC). Le patient cirrhotique est également concerné par les pathologies communes à la population générale, notamment la coronaropathie. Cependant, les cardiopathies des patients en attente de TH restent mal connues et aucune étude ne s'est intéressée à leur épidémiologie. Nous avons réalisé une étude descriptive rétrospective. Nous avons recueilli les données épidémiologiques et échocardiographiques pré-opératoires des patients transplantés pour cirrhose dans notre centre en 2011 et 2012 ainsi que de ceux qui étaient inscrits sur liste d'attente à la fin de l'année 2012. Des examens complémentaires pour évaluer la réserve coronarienne pouvaient être réalisés. Le diagnostic de CMC reposait sur plusieurs paramètres échocardiographiques de la fonction diastolique, la surface de l'oreillette gauche et l'allongement du QT [1]. Nous avons inclus 156 patients : 105 transplantés et 51 en attente de TH. Cinquante-cinq pour cent des patients présentaient un antécédent de tabagisme, 35 % une HTA, 23 % un diabète et 12 % une dyslipidémie. Tous les patients ont eu une échocardiographie, 29 une échographie de stress à la dobutamine (ESD), et 16 une coronarographie, dont 9 sans ESD préalable. La prévalence de la coronaropathie était de 10,2%. Huit patients étaient coronariens connus, 8 coronaropathies supplémentaires ont été diagnostiquées. La prévalence de la CMC était variable selon les critères diagnostiques, de 11 à 65 % (Tableau 1). La prévalence de la coronaropathie dans notre étude est inférieure aux données de la littérature nord-américaine (25 %). Moins d'un quart des patients a bénéficié d'une exploration de la réserve coronarienne, la prévalence est peut-être sous-estimée. La difficulté réside dans la sélection des patients à dépister, ainsi que du type d'examen à réaliser, l'évaluation clinique étant limitée par la faible activité physique de ces patients et le score de Lee n'étant pas adapté. Il n'existe pas de recommandations françaises spécifiques au cirrhotique pour la réalisation de ces explorations. La prévalence de la CMC est difficile à estimer en l'absence de critère diagnostique précis, d'où l'importante variation de prévalence observée. Les données de la littérature restent insuffisantes et traduisent la mauvaise connaissance de cette pathologie. Les critères actuels doivent encore être complétés. À défaut d'explorations diagnostiques performantes et de recommandations spécifiques au patient cirrhotique, le dépistage des cardiopathies des patients en attente de TH, pourtant essentiel pour optimiser leur prise en charge péri-opératoire, reste complexe et imparfait.

Introduction Les modifications hemodynamiques induites par une cirrhose evoluee peuvent etre responsables d’une atteinte cardiaque appelee cardiomyopathie du cirrhotique (CMC), definie par une alteration de la fonction systolique au stress, une dysfonction diastolique et des anomalies electro-physiologiques. Cette CMC pourrait jouer un role en transplantation hepatique (TH) dans la survenue d’un syndrome de reperfusion (PRS) et de decompensation cardiaque post-TH. Actuellement, les criteres diagnostiques de la CMC semblent insuffisants pour identifier les patients a risque. L’objectif de notre etude etait d’etablir, parmi les indices de dysfonction diastolique et d’elevation des pressions de remplissage du ventricule gauche (PRVG), lesquels etaient predictifs de survenue d’un PRS ou de dysfonction myocardique dans les 7 jours postoperatoires. Materiel et methodes Dans une etude descriptive retrospective realisee sur deux annees, incluant les patients qui ont beneficie d’une TH dans notre centre, nous avons recueilli les indices echocardiographiques pre-TH de dysfonction diastolique ou d’elevation des PRVG. Puis, nous avons identifie les patients ayant presente un PRS et/ou une decompensation cardiaque post-TH. Resultats Selon une regression logistique univariee (Tableau 1) sur 105 patients transplantes, seule la dilatation de l’OG pre-operatoire apparaissait comme facteur predictif de survenue d’un PRS ou d’une defaillance cardiaque post-TH. Quarante-deux pour cent des patients presentaient une OG dilatee. Ces patients presentaient un score de MELD significativement plus eleve (15,8 versus 13,2, p = 0,031) et plus de varices œsophagiennes (75 % versus 54 %, p = 0,019) par rapport au reste de la population. L’ITV sous-aortique etait egalement significativement plus elevee (26,7 versus 23,6 cm, p = 0,002). Discussion L’importance des modifications hemodynamiques liees a la cirrhose resulte de la gravite de l’hypertension portale, ce qui explique l’association OG dilatee et cirrhose evoluee observee dans notre etude. La dilatation de l’OG est un marqueur de dysfonction diastolique evoluee pouvant decompenser lors de modifications de conditions de charge telles que la revascularisation du greffon ou la periode post-TH, expliquant les resultats observes. Alors que la dilatation de l’OG est consideree comme un critere secondaire definissant la CMC, elle devrait etre consideree comme un marqueur primordial de CMC, dont la presence serait associee a une cirrhose evoluee et decompensee, et permettrait d’identifier les patients a risque de developper un syndrome de reperfusion ou une dysfonction cardiaque post-TH.

Since the outcomes of patients with candidemia is poor and Candida spp. with increased resistance to antifungal therapy may be associated with these results, the emergence of these blood infections caused by non-C. albicans Candida spp. was explored prospectively over a two-year period (2009-2010). Candidemia was defined as the recovery of Candida spp. in culture from a patient's blood sample. The in vitro susceptibility of each isolate to amphotericin B, caspofungin, fluconazole and voriconazole was determined. In addition, characteristics of patients and outcomes were investigated in real-time. The Candida distribution was compared to that observed in a similar study 10 years earlier in the same hospital. A total of 182 patients with candidemia were included in the study. While C. albicans was the most frequently isolated species (n = 102), non-C. albicans Candida spp. included; C. glabrata (n = 32), C. parapsilosis (n = 21), C. tropicalis (n = 13), C. krusei (n = 8), C. kefyr (n = 3), C. lusitaniae (n = 2), C. lipolytica (n = 2), C. famata (n = 1), C. guilliermondii (n = 1), C. inconspicua (n = 1), C. dubliniensis (n = 1), C. sake (n = 1) and C. nivariensis (n = 1). In seven patients, C. albicans was associated with another Candida spp. Surprisingly, this prospective study demonstrated that regardless of the department (intensive care unit or hematological department), Candida spp. distribution was no different from that found in the 1998-2001 survey, except for C. krusei. A reduction in the proportion of C. krusei isolates was observed from 2000-2010 (P = 0.028) as a result of its decreased recovery in the hematological department.

From a medical point of view, aging is characterized by a potential failure to maintain homeostasis under conditions of physiological stress. This failure is associated with an increase in vulnerability. Physiological changes associated with aging are progressive but concomitant injury or diseases may rapidly worsen the health status of the patient. Increasing age independently predicts morbidity and mortality. Hypertension and dyspnea are probably two of the most frequent risk factors in elderly patients. The history of the elderly patient should assess functional status, including cardiovascular reserve sufficient to withstand very stressful operations. The type of surgery has important implications for perioperative risk and emergency surgery, particularly in the elderly, is associated with a high risk of morbidity. Elderly patients who are otherwise acceptable surgical candidates should not be denied surgery based solely on their age and concerns for postoperative renal, cardiovascular, cognitive or pulmonary complications. Renal impairment becomes more prevalent with advancing age as the glomerular filtration rate decreases. The surgical site is the single most important predictor of pulmonary complications. Concerning postoperative comfort and neurological complications, age is the highest risk factor for developing dementia. Pain is underassessed and undermanaged. The elderly are at higher risk of adverse consequences from unrelieved or undertreated pain.