Pierre Schoeffler’s research while affiliated with University of Clermont Auvergne and other places

Contexte La littérature sur le stress infirmier fait état d’une culture d’acceptation des facteurs de stress au travail, ironiquement liée au contrôle des situations de travail pour gérer efficacement le stress. L’un des principaux modèles de perception du stress au travail est le modèle Karasek ou modèle Job Demand-Control-Support (JDCS). Cependant, on sait peu de choses sur les effets du niveau de qualification sur le stress vécu par les infirmiers, en particulier dans les services de soins médicaux urgents (soins intensifs, SAMU, urgences) Méthodes Une enquête utilisant le modèle JDCS a été menée auprès de 385 infirmiers travaillant dans services de soins médicaux urgents (soins intensifs, SAMU, urgences) d’un hôpital universitaire. Des questions spécifiques ont exploré des variables telles que le sexe, les unités de soins actifs, le niveau de qualification et l’expérience de travail. Résultats Deux cents questionnaires ont été retournés. Un niveau élevé de stress au travail a été mis en évidence sans effet de genre et en l’absence d’isostrain. Les infirmiers des unités de soins médicaux urgents étaient situés dans le quadrant de stress élevé du modèle JDCS. À l’inverse, les autres infirmiers sont généralement situés dans le quadrant « actif ». Un niveau de scolarité plus élevé était associé à un stress professionnel plus élevée et à un niveau de latitude décisionnelle plus faible. Conclusions Dans des services de soins médicaux urgents, un niveau de scolarité élevé était un facteur majeur lié à un stress au travail élevé et était associé à une perception d’un faible contrôle des situations de travail, qui peuvent tous deux être des prédicteurs de troubles mentaux. En particulier, le manque de contrôle a été associé à la détresse morale, une caractéristique fréquemment signalée dans les milieux de soins urgents. Des stratégies pour aider les infirmières à gérer les facteurs de stress quotidiens dans les soins actifs sont nécessaires.

Background: Lectures with slide presentations are widely used to teach evidence-based medicine to large groups. Take-home messages (THMs) are poorly identified and recollected by students. We investigated whether an instruction to list THMs in written form on slides would improve the retention thereof by residents, and the residents' level of knowledge, 1 month after lectures. Methods: Prospective blinded randomized controlled study was conducted. Twelve lectures (6 control and 6 intervention lectures) were delivered to 73 residents. For the intervention lectures, the lecturers were instructed to incorporate clear written THMs into their slide presentations. The outcomes were ability of resident to recollect THMs delivered during a lecture (as assessed by accordance rate between the lecturers' and residents' THMs) and knowledge (as assessed by multiple choice questions (MCQs)). Results: Data for 3738 residents' THMs and 3410 MCQs were analyzed. The intervention did not significantly increase the number of THMs written on slides (77% (n = 20/26), 95% CI 56-91 vs 64% (n = 18/28), 95% CI 44-81, p = 0.31) nor THMs retention (13% (n = 238/1791), 95% CI 12-15 vs 17% (n = 326/1947), 95% 15-18, p = 0.40) nor knowledge (63.8 ± 26.2 vs 61.1 ± 31.4 /100 points, p = 0.75). In multivariable analyses performed with all THMs written on slides from the two groups, a superior knowledge was associated with notetaking during lectures (OR 1.88, 95% CI 1.41-2.51) and THMs retention (OR 2.17, 95% CI 1.54-3.04); and THMs retention was associated with written THMs (OR 2.94, 95% CI 2.20-3.93). Conclusions: In lectures delivered to residents, a third of the THMs were not in written form. An intervention based on an explicit instruction to lecturers to provide THMs in written form in their slide presentations did not result in increased use of written THMs into the slide presentation or improvement of the THMs retention or level of knowledge. However, we showed that there was a strong positive association between writing THMs on a slide, retention of THMs and residents' knowledge. Further researches are needed to assess interventions to increase written THMs in lectures by faculty. Trial registration: ClinicalTrials.gov NCT01795651 (Fev 21, 2013).

Background Lectures with slide presentations are widely used to teach evidence-based medicine to large groups. Take-home messages (THMs) are poorly identified and recollected by students. We investigated whether an instruction to list THMs in written form on slides would improve the retention thereof by residents, and the residents’ level of knowledge, one month after lectures. Methods Prospective blinded randomized controlled study was conducted. Twelve lectures (6 control and 6 intervention lectures) were delivered to 73 residents. For the intervention lectures, the lecturers were instructed to incorporate clear written THMs into their slide presentations. The outcomes were ability of resident to recollect THMs delivered during a lecture (as assessed by accordance rate between the lecturers’ and residents’ THMs) and knowledge (as assessed by multiple choice questions (MCQs)). Results Data for 3,738 residents’ THMs and 3,410 MCQs were analyzed. The intervention did not significantly increase the number of THMs written on slides (77% (n=20/26), 95% CI 56–91 vs 64% (n=18/28), 95% CI 44–81, p = 0.31) nor THMs retention (13% (n=238/1791), 95% CI 12–15 vs 17% (n=326/1947), 95% 15–18, p = 0.40) nor knowledge (63.8 ±26.2 vs 61.1 ±31.4 /100 points, p = 0.75). In multivariable analyses, superior knowledge was associated with notetaking during lectures (OR 1.88, 95% CI 1.41–2.51) and THMs retention (OR 2.17, 95% CI 1.54–3.04); and THMs retention was associated with written THMs (OR 2.94, 95% CI 2.20–3.93). Conclusions In lectures delivered to residents, a third of the THMs were not in written form, even though the teachers were instructed to incorporate written THMs into their slide presentations. However, there is a strong positive association between writing THMs on a slide, retention of THMs and residents’ knowledge. Trial registration ClinicalTrials.gov NCT01795651 (Fev 21, 2013)

Background: Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce postoperative pain, in both static (i.e., at rest) and dynamic contexts (e.g., during coughing or mobilization), and reduced doses could improve their efficacy/tolerance balance. Objectives: To test this hypothesis of efficacy after open heart surgery, in which NSAIDs are poorly used, particularly for safety concerns. Study design: Randomized, double-blind trial. Setting: Single-center, French university hospital. Methods: Patients. One hundred patients at low risk of postoperative complications undergoing scheduled open heart surgery (97 analyzed). We tested intravenous ketoprofen, at a dose of 0.5 mg/kg-1 every 6 hours during the 48 hours following the end of sedation, after surgery. This standard protocol was compared to a similar one in which half doses were administered, to one with quarter doses, as well as to a placebo group. Analgesia was supplemented by acetaminophen plus self- and nurse-administered intravenous morphine. The primary outcome was the intensity of dynamic pain, assessed over 48 hours on an 11-point numerical rating scale (NRS). Results: Only the full-dose ketoprofen group showed reduced dynamic and static postoperative pain vs. placebo (P < 0.00001 for both). The evolution of dynamic pain suggested a delayed and therefore non-significant effect with the low doses. Ketoprofen did not affect either the postoperative morphine consumption or the tolerance outcomes, such as the volumes of chest tube drainage and the renal function. Limitations: This pilot trial was undersized to test major tolerance outcomes. Conclusions: Although we failed to demonstrate any analgesic effects with low doses of ketoprofen, we confirmed the good efficacy/tolerance balance with this propionic NSAID of intermediate COX2-selectivity. Lower doses of NSAIDs, potentiated by a loading dose, should be tested in the future.IRB approval: CPP Sud-Est VI (Clermont-Ferrand, France), on 12/23/2013.Clinical trial registry: EudraCT (2013-003878-27); ClinicalTrials.gov (NCT02180087).Key words: Non-steroidal anti-inflammatory drugs, ketoprofen, cyclooxygenase, pain, postoperative, sternotomy, postoperative rehabilitation, analgesia, side effects.

While both ephedrine and phenylephrine are currently used to treat hypotension occurring during carotid endarterectomy (CEA) under general anaesthesia, phenylephrine may have deleterious effects on the cerebral watershed, due to its exclusively vasoconstrictive action. In this controlled, double-blind randomised trial, we compared the effects of ephedrine and phenylephrine administered in a standardised algorithm to treat the first hypotensive event occurring since induction of anaesthesia until carotid cross-clamping. The algorithm consisted of 1-to-3 boluses of 6 mg of ephedrine or 50 μg of phenylephrine, after a goal-directed fluid therapy. In case of failure, the treatment switched to the other study drug. Cerebral tissue oxygen saturation (SctO2 ) was monitored by near infrared spectroscopy (NIRS), and the primary outcome was the restoring effect of SctO2 (ipsilateral to surgery) to baseline values. Secondary postoperative outcomes were: contralateral SctO2 , neurological outcomes, and plasma S100B protein measured at discharge from post-anaesthesia care unit. Ephedrine treatment provided a higher rate of restoration of ipsilateral SctO2 than phenylephrine (93.2% vs. 85.1%, P=0.034); this was also noted for contralateral SctO2 (93.5% vs. 90.7%, P=0.026). The gain in SctO2 on the lowest value during hypotension was also higher under ephedrine than phenylephrine (6.4% vs 4.3% ipsilateral, 5.1% vs. 4% contralateral), but not significantly so. Clinical outcomes were unaffected by the treatment, but S100B protein plasma concentration was higher in the phenylephrine group. To conclude, this pilot trial, focusing on intermediate outcomes, suggests that ephedrine should be preferred to phenylephrine to treat hypotension during CEA. This article is protected by copyright. All rights reserved.

Background: The continuous bilateral infusion of a local anaesthetic solution around the sternotomy wound (bilateral sternal) is an innovative technique for reducing pain after sternotomy. Objective: To assess the effects of the technique on the need for intensive care in cardiac patients at increased risk of respiratory complications. Design: Randomised, observer-blind controlled trial. Setting: Single centre, French University Hospital. Patients: In total, 120 adults scheduled for open-heart surgery, with one of the following conditions: age more than 75 years, BMI >30 kg m, chronic obstructive pulmonary disease, active smoking habit. Intervention: Either a bilateral sternal infusion of 0.2% ropivacaine (3 ml h through each catheter; 'intervention' group), or standardised care only ('control' group). Analgesia was provided with paracetamol and self-administered intravenous morphine. Main outcome measures: The length of time to readiness for discharge from ICU, blindly assessed by a committee of experts. Results: No effect was found between groups for the primary outcome (P = 0.680, intention to treat); the median values were 42.4 and 37.7 h, respectively for the control and intervention groups (P = 0.873). Similar nonsignificant trends were noted for other postoperative delays. Significant effects favouring the intervention were noted for dynamic pain, patient satisfaction, occurrence of nausea and vomiting, occurrence of delirium or mental confusion and occurrence of pulmonary complications. In 12 patients, although no symptoms actually occurred, the total ropivacaine plasma level exceeded the lowest value for which neurological symptoms have been observed in healthy volunteers. Conclusion: Because of a small size effect, and despite significant analgesic effects, this strategy failed to reduce the time spent in ICU. Trial registration: EudraCT (N°: 2012-005225-69); ClinicalTrials.gov (NCT01828788).

Background: Positive end-expiratory pressure (PEEP) has beneficial pulmonary effects but may worsen the hemodynamic repercussions induced by pneumoperitoneum (PNP) in patients undergoing liver laparoscopic liver resection. However, by the increase of intraluminal vena cava (VC) pressures, PEEP may prevent PNP-induced VC collapse. The aim of this original article was to test the validity of this hypothesis. Methods: After IRB approval and written inform consents, 20 patients were prospectively evaluated. Measurements were performed before and after the application of a 10 cmH2O PEEP on patient without PNP (Control group) and during a 12 cmH20 PNP. Results are in means [95%CI]. Comparison used paired-sample t test. Results: PEEP induced a decrease in CI in Control subgroup (2.3 [2.0-2.6] and 2.1 [1.8-2.4] l min(-1) m(-2) before and after PEEP. P < 0.05). In contrast, PEEP on a pre-established PNP did not significantly modify CI. Transmural pressure on abdominal vena cava decreased with PNP but was partly reversed by the addition of PEEP. Conclusion: The application of PEEP on a pre-established PNP during laparoscopic liver resection in normovolemic patients did not decrease CI. Analysis of transmural VC pressure variations confirms that the addition of PEEP may prevent the vena cava collapse induced by PNP.

Background: Polyamines have been identified as pain agonists and interact with N-methyl-D-aspartate receptors. A prospective, randomized, multicenter, and blinded phase II clinical trial was conducted to evaluate a polyamine-deficient diet for the treatment of perioperative pain in patients during spinal surgery. Methods: All analyses followed the intention-to-treat principle. The trial was designed to evaluate the dose-ranging effect of a low polyamine diet with respect to a total (group 1) or partial (group 2) polyamine diet on perioperative pain (7 d before and 5 d after surgery). Pain (numerical scale at rest and motion), quality of life questionnaires (Brief Pain Inventory, EIFEL questionnaire, and Short Form-12 acute questionnaire), and tolerance of and compliance with the nutritional program were measured. Results: Compliance (preoperatively: 100% in group 1 and 83% in group 2; postoperatively: 83% in group 1 and 71% in group 2) and tolerance were good. After 7 d following the diet before surgery, decreased pain was observed in group 1 whereas no effect was observed in group 2 (P = 0.144). This analgesic effect became significant in group 1 in the subgroup of patients with initial high levels of pain (NS ≥ 4) at rest (P = 0.03) and during motion (P = 0.011). Quality of life was significantly improved in group 1 (P = 0.0465). In the postoperative period, pain was significantly decreased in group 1 compared to group 2 at rest (P = 0.022) and during motion (P = 0.029). The effect was significantly better on patients with higher initial pain both at rest (P = 0.013) and during motion (P = 0.005) in group 1 compared to group 2. Conclusion: Suppression of polyamines from the diet offers a nutrition-based treatment option for perioperative pain reduction independent of and complementary to typical analgesic approaches.

Standard verbal or analogue scales may not be accurate to assess acute postoperative pain in elderly patients. This study was designed to field test the Algoplus tool, developed specifically for this population and based on observation of patient behavior. Prospective, observational cohort. Single center, French University hospital. Forty-eight patients, aged over 65, scheduled for surgery under general anesthesia, and observed on admission to the postanesthesia care unit, immediately after extubation, during the different steps of analgesic intervention (demand, relief with intravenous opioid titration, plus intermediate measures when relevant), and either at discharge or 3 hours after admission. A numerical rating scale (NRS) was used to guide analgesia. The Algoplus score and the state of alertness or sedation were noted. NRS scores and Algoplus scores were significantly related, and both scores significantly decreased under the effect of analgesia, but the correlation was low. In early observations, the Algoplus score was higher than that predicted by the NRS score, in relation to residual sedation. Female gender tended to lower the Algoplus score compared to the NRS score. When the NRS score exceeded 3/10, indicating the need for analgesic intervention, the Algoplus score was generally lower than the recommended trigger for analgesia (2/5). These results are promising, but further evidence of a clinical benefit to the use of Algoplus for acute postoperative pain is needed. In future studies, scoring should be adjusted to take into account the time from extubation, the state of sedation, and the patient's gender in order to interpret results.