“ le petit Robert ” dit :

Savoir:Avoir présent à l’esprit (qqch que l’on identifie et que l’on tient pour réel)Etre conscient deEtre en mesure d’utiliserAvoir présent à l’esprit dans tous ses détailsSouligne une affirmationÊtre capable par apprentissage par habitude de faire qqch,s’appliquer à ..par effort de volonté

Ensemble de connaissances (culture, instructions, science)

PouvoirAvoir la possibilité de faire qqchAvoir le droit, la permissionEtre capableLe fait de pouvoir

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Savoir et pouvoir: en pratique

Savoir: pouvoir dans le sens d’avoir appriscomment (Savoir→Pouvoir)

Pouvoir: verbe qu’on “sait” parfois remplacerpar savoir (Savoir Pouvoir)

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Clinical examples

Blood administrationAgePulmonary hypertensionRenovascular diseaseDefibrillator limitsLactate (Bentall, post Fallot)Professionalism

Up to how far should we limit exogenousblood administraion ?

68 yrs prof Dr EmeritusParoxystic atrial fibrillation and CADCABG (LIMA LAD; AO-vene-diag-RDP; Ao-FRIMA-Cx)+ epicardialPVI + LAA excision12h ICU: Hb 7,8 g/dl Hct 22% hypotension:inotropics (dobu 2µg/kg/min, nor 0,1 µg/kg/min),fluids (3L +)IBP 92/45mm Hg 96bpm Temp 36,7° C1U PC: frisson, nausea, malaise

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Medical indication : transfusion limits

Murphy GJ (Circ 2007) : limit =Hct 21,transfusion = 6x↑mortality risk at 30d(cardiac & pulmonary),γ if no major renal, cerebral or intestinal antecedents

Patient’s preference

Contextual features

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Age a cost-inducing and limiting factor ?

Man 92 yrs, MV disease: MS (gradient 17mm Hg) & MI 2/4 (multiple jets), atrialfibrillation, gardener, mentally optimalRepeated requests (3x) for surgeryMVR (Bio), stapling LAAExtubation: 3h; ICU: 36hAF: Cordarone postoperativelyLOS: 22d

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Did we have a choice? …

Repeated and convincing requestsYoung biological ageFamily supportCare for great-grand child

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Carottes

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Pulmonary hypertension

Female 85 years 9d inferior STEMI ,VSD 15 mm,Qp/Qs = 2,0; SPAP 60mm Hg, mental state: optimal

« Docteur, je ne veux pas mourir commeça, je me sens mourir à petit feu,remettez- moi vite d’aplomb… J’aitoujours été bien et ce n’est qu’aprèsque le remplaçant de mon généraliste aitaugmenté mes médicaments pour la tensionque je suis devenue malade »VSD-patch closure + CABG LIMA LAD; Ao-vene-RDPMilrinone, noradrenaline, NO + epoprostenolICU: 3d, delirium POD1-D2LOS: 28dtitel10 27/10/2016

Savoir: oui ? – pouvoir oui?

Observation timeMental stateRequest GP

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Medical indication

Age does not limit quality of life improvement incardiac valve surgery (Sedrakyan JACC 2003)

> 90 & 100 yrs: careful selection allows to reducerisk (Bridges CR J Am Coll Surg 2003)

Quality of life in the very elderly after cardiacsurgery: a comparison between long-term survivorsand an age - matched population population selection improves outcome

(Sjögren J, Gerontol 2004)

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Renovascular disease

Female 57yrs with syncopes after eatingVascular obstructive disease (Ao-Bifemor bypas,2011), mesenteral & vascular ischemia, 1 No &atrophic Kidney- 1 renal artery stenosis (CNI, Cr Cl15ml/min) (Cl III-IV), recent ARF, CADScheduling: TPL Insertion supra-renal aorta Dacronprothesis with reimplantation aa. Mes, TC and renalartery reanastomisis

“I am too young to be on dialysis”Planning:

Optimizing renal treatment and blood pressure (8W)BMS-stent in left main

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Renovascular disease (2)

Hickman catheter - thoracoabdominal aorticendarterectomy (CSF drainage- renoplegia)Postoperative course : Addison (CVVH≠)ICU 6d, LOS 12d; Cr Clear 25 ml/min outApproach:

Preoperative renal (and cardiac)optimizationSurgical downsizing and renoplegiaPre-per & post operation anesthesia managementAnxiety reduction

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Pouvoir? Et Savoir? Ou Espoir

Quality of life & contextγ Winning time before dialysisγ Preoperative optimization of kidneysγ Optimal surgical, anesthetic and renal plan

Secret wish: Camino Santiago Compostella!!

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Bentall post Fallot : lactic acidosis

52 yrs, Fallot-correction at 6 yrs, now AI ¾-4/4Bentall and MorrowFemoro-femoral ECC initiationDuring ECC ↑ lactate concentrations ( 8,5 mmol/l)

Meanwhile urgent unstable CABG

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Causes of lactic acidosis

Cardogenic or hypovolemic shock, advanced heart failureSepsisSevere traumaSevere hypoxemiaCO poisoningSevere anemia (Hb 8.3 mg/dL)Diabetes mellitus (without meformin)Cancer ( lymphoma, leucemia)Liver disease (moderate alcohol use)PheochromocytomaMetformin, Cocaine, Alcohols, glycols,cyanide, β2 agonists,propofol, <vit B1

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Unforeseen extension of surgery time

Options:Continue surgery and consult internal medicine (time>)End surgery quit femoro-femoral ECC-bypass l (time<?)Change femoral bypass to aortic -graft-RA-ECC-bypass(time ?), See what happens with lactate (time <<?)

Lesser efficacy of inotrope?Workload: AVR (3) or urgent unstable left-mainCABG (2)

?

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Bentall post-Fallot correction: lactic acidosis

Removal of femoral cannulation, aorticcannulation, reperfusion end-surgery↓ lactate (6 mmol/l)

Start urgencyFirst case: ICU within 6h: ↓ lactate ( 2,9 mmol/l)

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Defibrillator impactEsophageal-neo 37kg,43yr-old Jewish malecancer patient admitted for gastrostomy feedingtube revision under general anaesthesiaCAD, EF 23% with AICDAgrees with minor surgery but wants to die –repeatedly resuscitated by his AICD

Some AICD can’t be turned off (rate & output voltagecan ↓but difficult to switch off)Magnet overruling (St-J Med Biotronik, Bos Sci Guid)AICD specific DNR-order?Off-switching AICD request: religious susceptibilities

Pre-AICD discussion of AICD consequencestitel21 27/10/2016

Use caution when applying magnets topacemakers or defibrillators for surgery

Timely preoperative review andprogramming of AICD function as necessaryfor surgery (Schulman Anest Analg 2013)

We need to understand our electronics!It’s not just about the magnet! (Welner -Huang Anesth Analg 2014)

Creating an Anesthesiologist-run pacemakerand defibrillator service ! ( Rozner MA, Anesthesiol

2015)

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Decision making

l Medical indicationl Key factorsl Professionalism

l Patient’s preference- wishl Quality of lifel Contextual factors

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Medical indication: avoid harm

Acute- Chronic-Critical-Reversible-Emergent -Terminal?Goals: cure, improve or maintain?Relief of symptoms: pain, suffering?Health promotion?Prevention?Education of patientWhen not indicated ?

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Medical indication: 4K-factors

Autonomy: emphasizes the respect of the patient’swishes, values and religious belief and the patient’sright to continue withdraw to medical treatment free frominfluenceBeneficence: moral obligation to act for the benefit ofothers requiring the prevention of harm, removing ofharm and the promotion of goodNon-maleficence assumes the obligation not to inflictharm to othersJustice refers to a fair and equitable distribution ofbenefits and burden of all individuals in a society

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Professionals…

+ Accountability+ Humanism+ Ethical behavior+ Well-being

≠ Abuse of power≠ Bullying≠ Inadequate man. private info≠ Dishonesty≠ Conflict of interest≠ Fraud

≠ Sexual harassment

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Patient’s preference

In accordance with their wishes, values,religionRight to initiate, continue or withdraw fromtreatmentAssess: adequate information provided,understanding consent

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Quality of life

Prospect of the future, return to normal lifeBiases present for the provider’s evaluationEthical issuesPlans for life-sustaining treatment?Legal and ethical status of suicide?

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Contextual feature (justice, fairness)

FamilySocialInstitutionalFinancialLegalBusinessProfessionalOther parties of interestReligion

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Religious perspectives for end-of-life issues

Consider also the religious & culturalperspective↓ Confusion, conflict & untoward clinicalevents!Conflict prevention = better knowledge &respect of patient’s wishes

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Judaism, islam and catholicism

“The proprietor of human life is god”

Individual great diversity of views

Judaism: continuous versus intermittent treatment

Islam (and Judaism): religious advisor and welfare in

accordance with religious laws

Catholicism: focus on patient’s decision for treatment,

may decline extraordinary mean to preserve life

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2015

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Cost Health-BenefitHuman well-being

Savoir/ Pouvoir