Enquête nationale sur la pratique des « Revues de morbi-mortalité » en réanimation

Objective

A national survey was conducted by the “Collège français d’anesthésie et de réanimation (CFAR)” and the “Collège des bonnes pratiques en réanimation (CBPR)”, to analyze the implementation of morbidity and mortality conferences (MMCs) in French intensive care units (ICUs).

Study design

An electronic questionnaire was set up. We directed the survey at French ICUs physicians registered in the two Colleges directories, only one form was filled in by each participating unit.

Results

From December 2009 to February 2010, Among the 170 replies, 120 ICUs (71%) practiced MMC. No difference in the typology of the two groups was found. The median annual number of MMCs was 4 per year (1-15). The perimeter of the MMCs concerned only the ICU unit in 70 cases (58%), more than one ICU unit in the same department in 11 cases (9.8%), more than one department of ICU in 16 cases (13%) and other departments in 57 cases (48%). The events analyzed were: all deaths in 45 cases (37.5%), unexpected deaths in 50 cases (41.7%), severe adverse events in 67 cases (55.8%) and other events in 19 cases (15.8%). At least one adverse event defined by the two colleges in the process of “accreditation” was analyzed in 86 cases (72%). Participation of a physician of at least one other unit was reported in 56 cases (47%) and of medical students in 62 cases (52%). The low rate of participation of ICU nurses was reported in 62 cases (69.2%) and their absence in 35 cases (29%). MMCs consequences were drafting of new procedure in 99 cases (83%), changes in procedures in 75 cases (63%), conducting training programs in 60 cases (50%), organizational changes in 86 cases (72%), adverse event declaration in 21 cases (18%) and monitoring indicators in 40 cases (33%). Among units which did not practice MMCs, Identified obstacles were organizational causes in 25 cases (50%), inexperience in seven cases (14%), lack of methodology in 4 cases (8%), realization of other methods of formative assessment in 4 cases (8%) and physician's refusal in three cases (6%). The fear of medico-legal problem was never reported as a barrier to MMCs practice. Forty-five units (90%) projected to practice MMR.

Conclusion

This survey showed that the practice of MMR is common in French ICUs, allowing the identification of organizational problems, but also of training needs, joining one of the initial concerns that have led to their implementation. Expanding the participation to non-physician members of the units should be encouraged, without underestimating the difficulties particularly in the organizational domains that represent an obstacle to development of MMCs.     

Organisation des soins en analgésie,anesthésie et réanimation en maternité en France métropolitaine : résultats comparés des enquêtes nationales périnatales 2003 et 2010

Objective

The equipment and practices in obstetric analgesia, anaesthesia and intensive care, as well as their evolution between 2003 and 2010 in metropolitan France, were described.

Population and methods

Data were derived from two representative samples of births in 2003 and 2010, based on all births in France during one week. The sample included 534 maternity units and 14,903 births in 2010 and 618 maternity units and 14,737 births in 2003.

Results

The caesarean operating room was adjacent or inside the labour ward in 66% of maternity units in 2010 vs 56% in 2003. An anaesthetist was appointed permanently to the labour ward in 38.9% of maternity units in 2010 vs 21.5% in 2003. Locoregional analgesia or anaesthesia rate increased significantly: 81.5% in 2010 compared to 74.9% in 2003. Almost all operative vaginal deliveries were performed under epidural anesthesia in 2010. Patient controlled epidural analgesia (PCEA) was available in 58% of the units in 2010 but only 34.2% of women had PCEA. Newborn's resuscitations were performed mainly by paediatricians in 2010, but 11.4% of children were resuscitated by an anaesthetist in level 1 maternity units.

Conclusion

The conditions required to ensure anaesthetic care safety in maternity units has improved since 2003. Improvements in quality of care are still possible.     

Prise en charge anesthésique des transplantations hépatiques : évolution des pratiques périopératoires en France entre 2004 et 2008

Objectives

To determine the evolution of French perioperative anaesthetic practices in liver transplantation between 2004 and 2008.

Study design

Phone survey.

Methods

In 2004 and 2008, a similar questionnaire has been administered by phone to a senior anaesthesiologist from each French centre performing adult liver transplantation (n = 21). Results were compared using Fisher test and p < 0.05 was considered significant.

Results

Between 2004 and 2008, there was a trend towards an increase of centres performing transplantation for more than 40% of Child C patients (p = 0.1). Simultaneously, work force dedicated to liver transplantation cases has been reduced since in 2008, one anaesthesiologist was in charge in 90% of the centres (p = 0.06 vs 2004). Perioperative practices remained largely heterogeneous between centres with regard to hemodynamic monitoring, fluid and blood products management, antifibrinolytics use or postoperative analgesia.

Conclusions

This French survey has shown a reduction of work force dedicated to a liver transplantation from 2004 to 2008 simultaneously with a trend towards a greater severity of liver recipients. Practices heterogeneity reflect at least in part, unresolved questions about the best perioperative management for liver transplantation and the need for guidelines. Working for standardization of our practices and multicentric trials could allow gaining a better understanding of what should be the good practices in perioperative management of liver transplantation.     

Péridurale obstétricale : qualité de l’information médicale en français sur Internet en 2009 et 2010

Objective

The variability of the medical information available on the Internet (MedInfoWeb) raises concern about its quality. There is no data about the quality of MedInfoWeb concerning epidural analgesia for labour (EAL). Our aims were to assess the quality of MedInfoWeb concerning EAL and to study the stability of MedInfoWeb and the ranking of website into search engine (SE) during 1 year.

Study design

Observational study.

Materials and methods

We created our own data form to analyse the firsts 40 Google^®, Alta Vista^® and Yahoo^® websites. In 2009 and 2010, two independent assessors assessed the quality of the website structure (structure score noted out of 25) and the quality of medical information (medical score noted out of 30). The global score (noted on 55) was the addition of structure and medical scores. A HONcode labelling was noted.

Results

Between 2009 and 2010, the average global (23 vs. 22), structure (11 vs. 11) and medical (12 vs. 12) Scores were stable. The SE's quality was comparable. A SE website's rank was not related to its global score. The labelling HONcode websites were the best (26 vs. 21, P = 0.048). The best website in 2009 and 2010 was doctissimo.fr. In 2010, only 58% of the websites were still presents.

Conclusion

The quality of MedInfoWeb concerning EAL is poor and did not improve between 2009 and 2010. The MedInfoWeb is unstable: 42% of the websites disappeared in 1 year. No website or SE is currently able to give reliable medical information concerning EAL.     

Risque allergique en anesthésie pédiatrique

Objectives

To propose the different modalities of management of the allergic risk occurring during paediatric anaesthesia.

Study design

Literature analysis.

Methods

Literature research using the Medline^® database and MeSH format according to keywords, including publications in French and English since 1982.

Results

The overall incidence for anaphylactic reactions was estimated at one in 7741 anaesthetic procedures during paediatric anaesthesia. Latex anaphylaxis was mostly involved with an incidence at one in 10,159 anesthetic procedures. The risk factors of latex sensitization are known. Primary latex prophylaxis is efficient in patients at risk of latex sensitization. In contrast to adults, neuromuscular blocking agents (NMBAs) are rarely involved in children, with an incidence at 1 in 81,275 anaesthetic procedures. The Ring and Messmer clinical scale allows quantifying the severity and helps managing the care of immediate hypersensitivity reactions. Clinical symptoms associate cardiovascular, respiratory and cutaneous-mucous signs according to different severity grades. Epinephrine associated to fluid loading, remains the first-line agent in case of severe reactions. The allergological assessment is key to the management of these reactions and is required in order to identify the mechanism of the reaction and the culprit drug or substance involved.

Conclusions

Allergic reactions to NMBAs occurring during paediatric anaesthesia are rare whereas those with latex are more frequent. Therefore, the reduction of the allergic risk during paediatric anaesthesia essentially requires a latex-free environment.     

Prise en charge initiale en réanimation des traumatisés graves du bassin

Pelvic trauma care is complex since it is frequently associated with multiple injuries and may lead to dramatic and uncontrollable haemorrhage. After pelvic trauma, the mortality, around 8 to 10%, is mainly related to severe pelvic hemorrhage but also to extrapelvic injuries (thoracic, abdominal or brain injuries). It is therefore crucial to manage pelvic trauma in specialized trauma center. The initial trauma assessment aims to determine the role of the pelvic injury in hemorrhage to define the therapeutic strategy of pelvic trauma care (arterial embolisation/pelvic ring stabilisation). This review was performed with a systematic review of the literature; it describes the pelvic fracture pathophysiology, and the efficacy and safety of haemostatic procedures and with their respective indications. A decision making algorithm is proposed for the treatment of trauma patients with pelvic fracture.     

Analgésie péridurale obstétricale chez une parturiente atteinte d’un déficit en facteur XI : défi inconsidéré ou risque raisonné ?

The authors report the performance of a labour epidural analgesia in a 26-year-old parturient presenting a moderate factor XI (FXI) deficiency. If haemostasis disorders usually contraindicate an epidural analgesia (with a risk of epidural haematoma), a moderate FXI deficiency is not an absolute contraindication to perform such an epidural analgesia. Desmopressin, sometimes used in surgery to reduce the bleeding, was administered to withdraw the catheter in better haemostasis conditions. No neurological signs were observed.     

Dexmédétomidine et clonidine : revue de leurs propriétés pharmacodynamiques en vue de définir la place des agonistes alpha-2 adrénergiques dans la sédation en réanimation

Alpha-2 adrenergic agonists (“alpha-2 agonists”) present multiple pharmacodynamic effects: rousable sedation, decreased incidence of delirium in the setting of critical care, preservation of respiratory drive, decreased whole body oxygen consumption, decreased systemic and pulmonary arterial impedance, improved left ventricular systolic and diastolic function, preserved vascular reactivity to exogenous catecholamines, preserved vasomotor baroreflex with lowered set point, preserved kidney function, decreased protein catabolism. These pharmacodynamic effects explain the interest for these drugs in the critical care setting. However, their exact role for sedation in critically ill-patients remains open for further studies. Given the few double-blind randomized multicentric trials available, the present non exhaustive analysis of the literature aims at presenting the utilization of alpha-2 agonists as potential first-line sedative agents, in the critical care setting. Suggestions regarding the use of alpha-2 agonists as sedatives are detailed.     

La pupillométrie en anesthésie-réanimation

Pupil size reflects the balance between sympathetic and parasympathetic systems. Due to technological advances, accurate and repeated pupil size measurements are possible using infrared, video-recorded pupillometers. Two pupil size reflexes are assessed: the pupillary reflex dilation during noxious stimulation, and the pupil light reflex when the pupil is exposed to the light. The pupillary reflex dilation estimates the level of analgesia in response to a painful procedure or to a calibrated noxious stimulus, i.e., tetanic stimulus, in nonverbal patients. This might be of particular interest in optimizing the management of opioids in anaesthetized patients and in assessing pain levels in the intensive care unit. The pupil light reflex measurement is part of the routine monitoring for severely head-injured patients. The impact of pupillometry in this condition remains to be determined.