Décret d’anesthésie de 1994, chirurgie ambulatoire et responsabilité médicale : nécessaires réflexions sur l’inévitable conciliation entre réglementation et recommandations

Day surgery is often considered as a marker of the necessity of reorganizing the hospital to take care globally and so better meet the expectations of improvement of the management of patients. But the actual deployment of day surgery can also act as a real revelation of the stakes of conciliation between the regulations, which supervise professional practices and organization, and the functioning of hospitals. Between the regulations supervising hospitals and professional practices and the place of the recommendations, between the general legal framework of the medical activity and specific legal framework (decree of anesthesia of 1994) and the Evidence-Based Medicine, the pretext of the improvement of the patient flow in day surgery, recommended by several institutions (Sfar, ANAP, HAS), questions about the legal obligation of the passage of all the patients in the postanesthesia care unit (PACU). Seen under the angle of a legal action against a medical doctor, the study of the French jurisprudence reveals that every practitioner has to respect the recommendations and the Evidence-Based Medicine, and this in the standardized frame of the MD's activity and the respect for a very strict legal environment. The question of an obvious conciliation between all these measures arises today clearly. In the case of a potential conflict, the key of resolution, based only on legal standards (constitution, laws, decrees), is not enough for arbitrating. Applying that the only respect for the decree of anesthesia would be enough for exempting itself from any contentious risk does not satisfy more. There is a real difficulty defining the legal precise nature of the recommendations, so best practices as better organization, which are more and more frequently. Even if these recommendations originally had not their place in the hierarchy of the legal standards, they are brought in there today. There is a real brake in the deployment of the day surgery because the strict respect for the decree of 94 on the systematic passage in PACU can be paradoxical with a better quality of the care. Twenty years after the publication of the decree of anesthesia, it seems essential to ask at first if it's possible to fast-track discharge without any stay in the PACU and thus of the inevitable conciliation between all these measures. Secondly it's necessary of modifying this decree to impulse the deployment of the day surgery.     

Predictive factors of PACU stay after herniorraphy in infant: a classification and regression tree analysis

Introduction: Herniorraphy is a common surgical intervention in infants, particularly in those born prematurely. Prematurity and perioperative sedation have been shown to be risk factors for postoperative apnea. However, their influence upon PACU stay duration has not been evaluated. The goal of this study was to investigate predictive factors for PACU stay in infants undergoing herniorraphy. Material and Methods: This study is a retrospective analysis of perioperative data in infants <6 months of age undergoing herniorraphy during the period November 2007–November 2009. Collected data included age, gestational age at birth, post‐conceptional age, weight, weight at birth, type of anesthesia (spinal vs general), perioperative administration of opioids and paracetamol, duration of surgery, duration of PACU stay, and apnea in PACU. Data analysis used classification and regression trees (CART) with a 10‐fold cross‐validation. Results: Two hundred and ninety‐six patients were included in the analysis. Five parameters were found to predict the duration of PACU stay: a post‐conceptional age below 45 weeks, prematurity, general anesthesia, postoperative opioid administration, and the use of intraoperative regional analgesia. CRT method allows constructing a decision tree with eight terminal nodes. The percentage of explained variability of the model and the cross‐validation were 79.7% and 76.6%, respectively. Discussion: Our study allows construction of an accurate predictive tree for PACU stay during herniorraphy in infants <6 months. Parameters found to influence the duration of PACU stay were related to anesthesia techniques and perinatal outcomes.     

超声引导下外周神经联合阻滞在麻醉后恢复室中的应用

目的探讨超声引导下多重外周神经联合阻滞在PACU(麻醉后恢复室)中用于全麻下肢手术术后镇痛的有效性和可行性。方法选择本院2017年7-12月PACU单侧下肢全麻手术患者60例,随机分为地佐辛镇痛组(D组)和外周神经阻滞镇痛组(N组),每组30例。D组静脉注射地佐辛0.1 mg/kg。N组由同一名操作者根据手术部位镇痛需要,在超声引导下实施神经阻滞,局麻药采用0.375%罗哌卡因。结果与D组比较,N组术后30 min、60 min、4 h、12 h静息和运动VAS评分均明显降低(P<0.05)。D组和N组PACU停留时间[(52.7±3.4) min vs.(50.0±4.2) min]、PACU内地佐辛的用量[(2.9±3.6) mg vs.(0.7±2.1) mg]、追加例数(12例vs.3例)和术后24 h病房内使用镇痛药的例数(17例vs.4例)比较差异均有统计学意义(P<0.05)。D组术后24 h出现恶心4例、呕吐3例,嗜睡7例,N组均未发生,两组比较差异有统计学意义(P<0.05)。D组和N组术后24 h总体满意度中满意率(23.3%vs.50%)和一般满意率(26.7%vs.3.3%)比较差异有统计学意义(P<0.05)。结论在PACU中利用超声引导下外周神经阻滞对全麻下肢手术患者实施术后镇痛是有效和可行的。外周神经阻滞可以提供较好的术后镇痛,缩短PACU停留时间,降低术后镇痛药使用量,不良反应少,总体满意度较高。     

Nurses' Perceptions of Patient Participation in the Postanesthesia Care Unit—A Qualitative Focus Group Study

PurposeTo explore postanesthesia care unit (PACU) nurses' experiences and perception of patient participation during PACU care.DesignQualitative focus group study based on a phenomenological hermeneutic approach.MethodsWe conducted three focus group interviews with 18 nurses from three different PACUs. Themes were created based on interpretive theory inspired by Ricoeur.FindingsFour themes and 11 subthemes were found. Patients’ clinical condition and situation, time management, ethical aspects, and the patient-nurse relationship all had a high impact on postanesthesia nursing practice and conditions for involving patients.ConclusionsPACU nurses want patients to participate in their own treatment and care in the PACU; however, nurses perceive patient participation differently. Nurses experience challenges including patients’ impaired autonomy, absence of a holistic approach, and lack of time and resources. Nurses highlight that these barriers should not become an excuse for noninvolvement.     

Comparison of tramadol/acetaminophen fixed-dose combination,tramadol, and acetaminophen in patients undergoing ambulatory arthroscopic meniscectomy

Objectives

Preemptive analgesia is a technique in which analgesics are administered before a surgery to provide better postoperative pain relief with fewer side effects. In this study, we aimed to compare the preemptive efficacy of tramadol/acetaminophen fixed-dose combination, tramadol, and acetaminophen in patients undergoing ambulatory arthroscopic partial meniscectomy.

Microbial contamination of manually reprocessed,ready to use ECG lead wire in intensive care units

Background: A number of studies have shown that non-critical medical devices can be contaminated with pathogens, including those resistant to antibiotics and thus become a potential vector for transmission. Electrocardiography (ECG) lead wire are non-critical medical device which are always attached on patient skin during their stay in intensive care unit (ICU). In view of the patient’s critical conditions and exposure to invasive procedures, identification and prevention of possible risks are important to prevent infection in ICUs. Objective: The objective of this study was to determine the presence of bacterial and fungal contamination on cleaned and disinfected reusable ECG lead wires in intensive care units in a hospital.Methods: A total of 408 cleaned ECG lead wires from 93 bed-side ECG devices and 43 ECG lead wires from 5 portable ECG devices from 4 intensive care units (ICUs) and 1 post-anaesthesia care unit (PACU) were sampled. ECG lead wires were stirred in 0.89% NaCl with added neutralizer for 30 seconds. Samples of the solutions were cultured directly on blood agar. The remaining solution was cultured on blood agar after sterile filtration. The number of colony forming units (CFUs) was counted and the microorganisms were identified.Results: More than half of examined ECG lead wires (n=232; 51.4%) were contaminated with >30 CFUs/mL sample of bacteria or with risk pathogens. Gram-positive bacteria were the most frequently isolated organisms; particularly, coagulase negative staphylococci (96%) and aerobic spore forming bacteria (71.2%). Compared to ICUs, PACU had significantly lower proportion of contaminated ECG lead wires (p<0.05). The proportion of contaminated ECG lead wires, as well as mean number of cfus per ECG lead wire, was also significantly lower among multi-wire ECG leads compared to single-wire ECG leads. Conclusions: Manually cleaned ECG lead wires may serve as a vector for transmission of nosocomial pathogens. The current reprocessing technique for ECG lead wires needs to be improved.     

羟考酮注射液对胃癌手术患者全麻后在恢复室的应用

目的：探讨盐酸羟考酮注射液对上腹部手术患者全身麻醉后入恢复室（PACU)中的应用。方法方便选择2013年3月—2015年5月该院实施胃癌手术患者80例,ASAⅠ~Ⅱ级。实施同样的麻醉方案,术毕所有患者转入PACU。由PACU医师随机分为盐酸羟考酮注射液组（A组,n=40)和硫酸吗啡注射液组（B组,n=40),接注射泵（0.9%生理盐水将两种药物稀释至1 mg/mL)按1 mg/kg泵入。由PACU医师观察并记录患者拔管前5 min、拔管时及拔管后15 min的MAP、HR、SPO2及拔管后恶心呕吐等不良反应。结果与B组比较,A组拔管前后的MAP（128.6±11.2)、HR（90.3±4.1)、SPO2（77.6±11.0)较平稳且差异有统计学意义（P﹤0.05)。拔管后统计的各种不良反应的总数A组较B组明显偏少且差异有统计学意义（P﹤0.05)。拔管后5min、15 min、30 min的VRS痛觉评分两组比较差异无统计学意义（P>0.05)。期间2组均未发生严重不良反应,且所有患者在PACU中过程基本平稳,顺利出室。结论盐酸羟考酮注射液对胃癌手术患者在PACU中应用安全有效,镇痛效果与吗啡相当,但较吗啡使用后血流动力学更平稳,拔管后恶心、呕吐等不良反应发生率更低。     

腹腔镜与剖腹胆囊切除术后患者在PACU并发症比较

目的比较腹腔镜胆囊切除术（LC）与剖腹胆囊切除术（OC）后患者在麻醉恢复室（PACU）的并发症的发生情况,探讨不同并发症的处理方法及护理策略。方法选取本院2009年12月～2012年12月胆囊炎、胆石症患者1754例,按术式不同,分为LC组和OC组。采用Roberta的麻醉恢复室并发症指标,对腹腔镜和剖腹胆囊切除术后患者在PACU内发生并发症进行比较。结果两组患者循环呼吸并发症无明显差异;恶心呕吐的发生率LC组明显高于OC组（P〈0.01）;疼痛的发生率OC组高于LC组（P〈0.05）;其他并发症的发生率两组间差异无统计学意义（P〉0.05）。ASAⅢ级患者并发症的发生率明显高于ASAⅠ、Ⅱ级患者,尤其是LC组。结论对于腹腔镜下胆囊切除术需注意消化道症状,剖腹胆囊切除术加强疼痛的观察和处理。对ASAⅢ级以上的患者尤其是腹腔镜手术的患者,需加强术中和术后的管理和护理,有助于及时发现和降低患者术后并发症。