Traçabilité de la gestion de l’utilisation des curares dans le dossier d’anesthésie en chirurgie viscérale : une étude observationnelle et multicentrique

Objectives

To report any item documenting the peroperative muscle relaxant effects management in anaesthesia files issued from visceral surgery processes.

Type of study

Prospective, observational and multicenter.

Patients and methods

A single operator analysed 1453 files proposed by nine anaesthetists’ teams. The items selected concerned three periods: induction/tracheal intubation, paralysis maintenance, tracheal extubation. Reporting of 40 categories of items was studied.

Results

Items related to laryngoscopy and intubation conditions were observed in 43% (0-95) [general average (intercentres min-max)] and in 11% (0-97) of the files, respectively. At least one level of paralysis was reported in 23% (0-96) of the files. For the paralysis maintenance, documentation of an effect appeared in 53% (4-96) of the documents. Neuromuscular assessments preceding the tracheal extubation were retrieved in 43% (12-89) of the notes. Adductor pollicis was concerned for 30% (1-89) of these observations. Detection of level of spontaneous paralysis offset, satisfying to the local standard, appeared in 14% (3-19) of the documents. Pharmacological reversal was noted for 25% (4-67) of the patients; the assessment of the effects so produced was reported in 8% (0-58).

Conclusion

In the studied collection, the traceability of the peranaesthetic curarization management appears variable on both qualitative and quantitative levels. The emergence of a dedicated guideline - defining the criteria for producing a good documentation of the muscle relaxant use - becomes necessary to secure these practices for all physicians using muscle relaxants.     

Besoins,intégration,conditions de travail des anesthésistes-réanimateurs remplaçants dans les centres hospitaliers généraux en région Rhône-Alpes

Objectives

To evaluate the need for locum anaesthetic coverage and the practical consequences (integration, working conditions, quality and safety) arising during the first 5 days of work, when a temporary position is accepted.

Measured parameters

1) Telephone enquiry of administrative services of community hospitals (CH) in one French administrative area (Rhône-Alpes) about their need for locum anaesthetists; 2) if a position was offered, it was accepted when the participation to on-call duties was delayed after the first 5 days of work; 3) during the working period, the following characteristics were assessed: integration of the locum anesthesiologist among team members, comparison of practice patterns to national guidelines; 4) data from the Platines-website of the French Ministry of Health were used to quantify indicators of activity and size of the hospitals and search for correlations between these parameters and working conditions of the locum anaesthetist.

Results

Of the 32 CH questioned, 28 were looking for temporary anaesthetic work force but only 11 (35%) accepted a 5-day period before participation to on-call duties and 17 refused this integration period. Four CH declared not to be looking for temporary work force. Characteristics of integration of the locum anaesthetist and standards of work were very different among centers. No hospital administration had a strategy for evaluation of recruited locums.

Conclusion

Temporary work force in anaesthesia is widely required in CH of the Rhône-Alpes area but this practice had not been formalised. No recruitment strategy was observable. This questions about the institutions’ requirements for anaesthetic services in French public hospitals.     

Comparaison des valeurs de débit cardiaque obtenues à l’aide d’un nouveau système d’impédancemétrie thoracique avec les données du cathéter artériel pulmonaire en postopératoire de chirurgie cardiaque

Objective

Thoracic bioimpedance has been proposed for cardiac output (CO) determination and monitoring without calibration or thermodilution (ICG Monitor 862146, Philips Medical System, Philips, Suresnes, France). The accuracy and clinical applicability of this technology has not been fully evaluated in the cardiac surgery setting. We designed this prospective study to compare the accuracy of the ICG Monitor (CO_ICG) versus pulmonary artery catheter standard bolus thermodilution (CO_PAC) in patients after cardiac surgery or having benefited from cardiac surgery.

Study design

Prospective, monocentric.

Material and methods

We studied 13 patients in the postoperative period. CO_ICG and CO_PAC were determined at the arrival in the intensive care unit and every four hours. Bland-Altman and Critchley and Critchley's analysis were used to assess the agreement between CO_ICG and CO_PAC.

Results

CO_PAC ranged from 2.6 to 11.0 l/min and CO_ICG ranged from 1.8 to 11.7 l/min. There was a significant relationship between CO_PAC and CO_ICG (r = 0.61 ; p < 0.001). Agreement between CO_PAC and CO_ICG was −0.5 ± 1.3 l/min (Bland-Altman analysis). Percentage error between the two methods was 49% (Critchley and Critchley's analysis).

Conclusion

We found clinically unacceptable agreement between CO_ICG and CO_PAC in this setting. Despite its non invasiveness, this device cannot be recommended for CO monitoring in the postoperative period following cardiac surgery.     

Facteurs prédictifs de défaillance d’organes chez les patients admis en réanimation pour hémorragie digestive aiguë

Introduction

Gastrointestinal hemorrhage is an emergency requiring usually an admission in intensive care unit (ICU), which may prove abusive secondarily. The aim of this study was to identify predictive risk factors of organ failure in patients admitted for GH in our ICU.

Design

Retrospective and observational

Methods and measurements

Between January 2008 and December 2011, all patients admitted in our ICU for gastrointestinal hemorrhage were consecutively included. The primary endpoint was the occurrence of at least an organ failure. We realized an univariate analysis then a backward regression to identify independent risk factors associated with the occurrence of at least one organ failure during the ICU hospitalization.

Results

During this period study, 441 consecutive patients with a mean age of 67 ± 15 years were included. The median ICU length of stay was of 4 (3–7) days and 116 (26% [IC95%: 22–30]) patients presented at least one organ failure. The multivariate analysis identified predictive risk factors of organ failure: history of cirrhosis (OR = 3.5 [IC95%: 1.9–6.7], P < 0.001) and an increase in troponin at the admission above the 99th percentile (OR = 3.1 [IC95%: 1.8–5.5], P < 0.001).

Conclusion

Our results confirmed that a large proportion of patients admitted in ICU for the primary diagnosis of gastrointestinal hemorrhage developed any organ failure. The history of cirrhosis and the systemic consequences of the hemorrhagic syndrome as myocardial damage represents important risk factors of morbidity and mortality and thus should be considered during the management.     

Évaluation des pratiques de gestion des cathéters veineux centraux dans les réanimations chirurgicales universitaires françaises

Introduction

Recommendations on insertion and maintenance of central venous catheters (CVC) in intensive care unit (ICU) patients were updated in 2002. The aim of this study was to estimate their knowledge and/or application by physicians in French university hospital ICUs.

Methods

Two forms were sent to 124 professors of anaesthesia and intensive care encouraging them to participate to the survey. The first one was completed by the physician in charge of each unit and concerned the structure and activity of the unit in 2006. The second one was filled by each junior or senior physician working in the units and asked for experience, CVC insertion modalities and knowledge of CVC care protocols.

Results

Forty-one (75 %) university hospitals with at least one adult surgical ICU took part to the study. A questionnaire was filled by 124 senior (75 % of the staff) and 53 junior (43 % of the staff) physicians inserting an average of 10 CVC per month (range, 1–35). A written protocol for CVC insertion was known by 127 (72 %) of them. CVC insertion was done while wearing sterile gown (97 %), cap (100 %) and surgical mask (100 %) and using large sterile draps (96 %). The antiseptic solution used for cutaneous antisepsis was povidone iodine in aqueous (36 %) or alcoholic solution (40 %), or an alcoholic solution of chlorhexidine (24 %) applied one (9 %), two (64 %) or three (27 %) times before insertion. A 4-times disinfection sequence (washing, rinsing, drying and disinfection) was performed by 161 (91 %) physicians. Ultrasound-guided insertion was realized by only eight (5 %) operators. CVCs were made of polyurethane (84 %), usually multi-lumens (> 96 %) and rarely tunnelised (14 %). Only two physicians (1 %) sometimes use catheters coated with antibiotics or antiseptics. The site for catheter insertion was mostly the sub-clavian (47 %) or internal jugular vein (34 %), and rarely the femoral vein (20 %). CVCs were secured with a thread (99 %) and covered with a semi-permeable dressing (76 %). Concerning CVCs maintenance, 91 % of physicians acknowledged the existence of a written protocol in the unit. Dressings were changed every day (10 %), every two days (49 %), every three days (29 %) or every four days or more (12 %) by using the same antiseptic solution and semi-permeable transparent dressing in 78 % of cases. Venous lines changes were done during dressing maintenance (48 %), every day in case of administration of lipids (32 %) or just after administration of blood products via the catheter (32 %). Routine change of CVC was rarely recommended (11 %).

Conclusion

The high number of answers allows setting of a precise state of CVCs insertion practices in adult surgical ICUs. Recommendations for central venous catheter insertion and maintenance are not still known and\or applied.     

Évaluation des motivations de choix et de leur cursus d’apprentissage par les internes d’anesthésie-réanimation : enquête nationale

Introduction

The duration of Anesthesiology and Intensive Care (AIC) residency increased from four to five years in 2002 in France. AIC is a specialty increasingly chosen in relation to medical and surgical specialties. We conducted a national survey by questionnaire on the evaluation of their theoretical and practical training by the French residents.

Material and methods

A questionnaire (demographics, motivations for the choice, training) was sent to 1422 residents, enrolled since 2002, in each province.

Results

In total, 562 questionnaires (40 %) were returned. The mean age of residents is 28 ± 2 years, 46 % are women, on average in 6th semester [1–10th]. The obtained specialty was their first choice for 90 % and of the obtained city home for 73 %. Residents declare that the place of their definitive installation will be chosen depending on the quality of life mainly. So, 97 % referred the same choice of specialty. Training in locoregional anaesthesia (LRA) was evaluated correct or good by 53 % of residents and in the management of difficult intubation correct or good by 62 %. Theoretical training was assessed correct by 31 % of responders and good by 53 % and practical training correct by 25 % and good by 61 %.

Discussion

The AIC is now a specialty of positive choice by students. This choice is reinforced by teaching and practice during the residency. The global training is as good as a whole. Residents wish to deepen in some areas (ultrasound, LRA, critical reading, medical redaction) and an evaluation of their practical training with simulations.

Conclusion

French AIC residents seem satisfied with almost all their training and referred the same choice of specialty.     

Impact d’une démarche d’évaluation des pratiques professionnelles sur l’utilisation du monitorage de la curarisation et l’antagonisation des curares

Introduction

As part of a quality assurance in the anaesthesia department, this study was designed to enhance the rate of neuromuscular blockade monitoring for patients receiving muscle relaxant during anaesthesia.

Methods

After approval of our local ethical committee, we assessed 200 computerized anaesthesia records in which neuromuscular relaxants were used. The following data were collected: demographic characteristics, durations of anaesthesia and surgery, use of neuromuscular monitoring, reversal agents and the quality of neuromuscular monitoring. The results were discussed with all anaesthesia providers of the department and an internal guideline was elaborated with the endpoint that all patients having muscle relaxants should have quantitative neuromuscular monitoring. Six months later, another assessment of 200 consecutive records collected the same data to check the efficiency of the elaborated guideline.

Results

The monitoring rate was of 67% at the first assessment and increased to 94% (p < 0.05). The reversal rate was at 48% in the first assessment and was stable at the second assessment (50%). The rate of patients not monitored and not reversed decreased from 5 to 2% (p < 0.05).

Discussion

This study shows that as part of a quality assurance program systematic quantitative monitoring of neuromuscular blockade can be significantly increased.     

Monitorage de la dilatation pupillaire dans l’évaluation d’une tolérance aiguë au rémifentanil en chirurgie cardiaque

Introduction

Remifentanil is a powerful morphinic agonist often ordered for anaesthesia. The use of peroperative large doses of this opioid increases the risk to develop postoperative hyperalgesia and acute tolerance. But how early these effects can occur? Despite the fact that these effects could be masked during the preoperative time because of general anaesthesia, it seems they could occur precociously. In order to try to describe this time, this study evaluated the acute tolerance under general anaesthesia requiring large doses of remifentanil by using an effective peroperative monitoring of nociception: the continuous pupillary diameter monitoring.

Materials and methods

In this prospective observational clinical study, a continuous infusion of remifentanil was started at a range of 0.3 μg/kg/min after induction of anaesthesia by using propofol (TIVA), remifentanil bolus and cisatracurium. The pupil monitoring started 10 min later (T + 10 min) and lasted until the surgical incision (T + 65 min). So, there was no surgical stimulus during this time.

Results

Thirty patients undergoing major cardiac or vascular surgery were included in this study. The continuous pupil diameter evaluation showed a significant increase of the pupil diameter from T + 45 min. No significant variation of heart rate, blood pressure, bispectral index (BIS) values were observed.

Discussion

The development of acute remifentanil tolerance could possibly explain these results. If evaluations with continuous pupillary diameter monitoring are still limited, these results suggest that the use of powerful opioids such as remifentanil should be associated with a N-methyl-d-aspartate (NMDA) receptor antagonist agent, including short time administrations.     

Prise en charge des nouveau-nés naissant dans un liquide méconial : évaluation prospective des pratiques

Objective

Regional guideline for immediate tracheal suctioning (ITS) in vigorous and non-vigorous infants born through meconium-stained amniotic fluid (MSAF) has been established in 2003. The objective of this study was to evaluate guideline application.

Study design

Prospective cohort.

Patients and methods

The first part of the study was a short survey about ITS practices in maternity hospitals then, management and early evolution of babies born through particulate MSAF was evaluated by questionnaire.

Results

Among 6761 neonates, 199 (3%) were born with MSAF. Early clinical evaluation showed 52 (26%) non-vigorous neonates; 22 of them (42%) have had an ITS. One hundred and forty-seven neonates were vigorous (74%); 27 of them (18%) have had an ITS. Implementation of recommendations in non-vigorous babies was better in maternities of level III, while they were lower in maternities of level IIA for vigorous babies. Among 52 non-vigorous children, eight had a meconium aspiration syndrome (MAS), including five who had an ITS. One MAS occurred in vigorous babies but infection could not be excluded.

Conclusion

Recommendations for ITS were implemented in 70% of cases but only in 42% of cases in non-vigorous babies. We have to improve formation and circulation of new recommendations.     

Résultats d’une enquête nationale évaluant l’utilisation des scores de sédation en médecine préhospitalière

The primary goal of sedation in emergency prehospital care is to guarantee the security of the mechanically ventilated patients by optimising their adaptation to the respirator. If the French prehospital guidelines are well codified, their applicability in routine clinical practice seem to be rather empirical. The aim of this national survey was to evaluate the use of the clinical sedation scales by the prehospital physicians. This prospective and clinical practice survey was begun in January 2005. An anonymous questionnaire was sent to the physicians working in the 377 Mobile Intensive Care Unit of the 105 French Emergency Medical Service System.     

Impact économique des stratégies de recours à l’éphédrine en seringues préremplies

Objectives

Ephedrine is an emergency drug available in ampules and syringes need to be prepared in advance according to one of two strategies in our establishment: strategy 1 (S1: 1 ampule per patient) and strategy 2 (S2: 1 ampule per operating room). There are also prefilled syringes. Because of their high cost and conflicting results in the literature, we assessed the economic interest of using prefilled syringes compared with strategies S1 and S2.

Type of study

This was a prospective observational study.

Patients and methods

The consumption of ephedrine was recorded over two periods of 14 days: P1 with syringes prepared in advance according to S1 or S2 and P2 with the on-demand use of prefilled syringes.

Results

The cost of a syringe of ephedrine prepared in advance (nurse time preparation included) was evaluated at €1.65 vs. €3.57 for a prefilled syringe. In operating rooms using S1, the use of prefilled syringes reduced overall the cost per patient about €1.22 and global annual costs by 72% (€2830), while the decrease was about €0.32 for the cost per patient and about 47% (€2760) for global annual costs for operating rooms using S2.

Conclusion

The interest of our study is that we investigated different supply strategies for ephedrine within a large number of operating rooms. In our establishment, it was decided to use prefilled syringes in operating rooms that used S1. As well as the economic interest, prefilled syringes contributed to improved safety and saved nursing time.