Enquête sur les pratiques françaises d’analgésie en chirurgie thoracique (réalisée avec le concours de l’ARCOTHOVA)

Objective

To assess the current practice of analgesia after thoracotomy and thoracoscopy in France.

Study design

Cross-sectional practice survey.

Material

Anaesthetist physicians, each referent for one of the French centres practicing thoracic surgery, during year 2012.

Methods

Electronic questionnaire about the activity of the centre in thoracic surgery, and modalities and estimated frequencies of different analgesic techniques. Primary assessment was the estimated percentage of acts, after imputation from original data.

Results

Eighty-four centres out of 103 (82 %) answered the questionnaire. Coupling locoregional to general anaesthesia involved 74 % of thoracotomies and 35 % of thoracoscopies. A practice (i.e. for more than 5 % of patients) of epidural analgesia was declared by 68 centres (81 %), and by 27 centres (32 %) for paravertebral block. The most current practices for epidural analgesia were: thoracic puncture, intraoperative initiation, ropivacaïne 0.2 % plus sufentanil, patient-controlled administration with infusion plus bolus, application more than 48 hrs post surgery. The practice rates for technique of paravertebral block were: Eason & Wyatt 34 %, ultrasound-guided 24 %, internal 42 %. The most frequent systemic analgesia was patient-controlled intravenous morphine. Ketamine was used in 60 % of the cases.

Conclusions

French practice of analgesia after thoracic surgery improved quality during the last decade, but more than one patient on four (compared to 8 % in UK) may have neither epidural nor paravertebral block, while such techniques are nowadays considered as standard.     

Enquête nationale sur l’utilisation du rémifentanil comme alternative à l’analgésie péridurale obstétricale dans les maternités de niveau II et III

Objectives

The last French survey on alternatives to neuraxial anaesthesia for labour pain was published in 1997. However, intravenous remifentanil has become increasingly used as an option for labour analgesia. We evaluated the use of remifentanil as an alternative to epidural analgesia in level 2 and 3 French maternities in 2009.

Study design

This was an internet-based French survey performed in 2009 including all level 2 and 3 maternities. Data recorded were maternity unit characteristic, alternatives to neuraxial analgesia used, and remifentanil administration protocols.

Results

Two hundred and forty maternity units received the survey and 103 responses were completed. A written institutional alternative analgesia protocol for labour pain was present in 78%. Alternative labour analgesia included intermittent nitrous oxide inhalation (58%), intravenous nalbuphine (52%), patient-controlled intravenous administration of remifentanil (52%) and sufentanil (46%). Pethidine administration was reported by one maternity unit (1%). The bolus dose of remifentanil scheduled, and background infusion varied widely between maternity units. The analgesic efficacy of remifentanil used for labour pain was evaluated as moderate (55%) or good (43%). Two serious adverse events were reported.

Conclusion

Intravenous administration of remifentanil was largely reported as an alternative to neuraxial anaesthesia for labour pain. Although remifentanil administration was most often based on a local written protocol, bolus dose and background infusion varied widely between maternity units.     

Gestion des voies aériennes supérieures en fin d’accouchement : enquête de pratique

Objective

To describe the airway management during general anaesthesia performed at the end of labour.

Study design

Observational retrospective study in a French university obstetrical unit.

Patients and methods

All parturients who underwent general anaesthesia for manual removal of the placenta or instrumental delivery were included. Demographic data, anaesthesia management, indication and duration of anaesthesia were recorded. Incidents as vomiting, a drop in oxygen saturation of five points or more, aspiration and difficult endotracheal intubation were investigated.

Results

Among 111 parturients with inclusion criteria, the rate of tracheal intubation was 5%. The duration of anaesthesia ranged from five to 60 minutes (mean duration: 16 min). No incident was recorded within the methodological limits of this retrospective study.

Conclusion

There is a major discrepancy between guidelines and clinical practice in our unit concerning systematic tracheal intubation during general anaesthesia performed at the end of labour. A national survey is in process to confirm these results.     

Enquête sur les modalités de la curarisation et la décurarisation au Maroc

Objective

To determine current clinical neuromuscular use in Morocco anesthetic practice.

Study design

Clinical practice survey.

Methods

Anesthesiologists were invited to answer anonymously to question about neuromuscular blocking agents (NMBA): pharmacology, monitoring and antagonism drug use. Corrected yates test was used to compare qualitative parameters and variance analysis for quantitative parameters. P < 0.05 was considered as significant.

Results

We had 171 answers, 54% were paramedics (n = 93) and 46% (n = 78) were physicians (20% global effective in Morocco). Fifty-five percent were seniors. Vecuronium was the most NMBA used in Morocco for 51% of the anesthesiologists. Mean action time of NMBA was underestimate in more than 60% of the staff questioned specially for seniors (24.6%) than juniors (19.2%). Residual neuromuscular blockade was evaluated only by clinical and spirometric parameters in 72%. TOF monitor was used in 18% more in military hospitals (36%) and insurance clinics (40%) than private hospitals (12.5%). Administration of reversal drugs was systematic in 5.8% of anesthesiologists, frequent for 36.3% and rare for 55%.

Conclusions

This study show an underestimation of residual neuromuscular blockade, poor neuromuscular monitor use and lack of knowledge of NMBA specially for senior anesthesiologists and in private hospitals. We should elaborate Moroccan guideline for NMBA use and provide formal training programs for our anesthetic staff.     

Enquête nationale sur l’assistance circulatoire et respiratoire de courte durée en 2009

Objective

Indications for short-term circulatory and/or respiratory support (STCRS) increased during the last years. The goal of this survey was to characterize this activity in France in 2009.

Study design

Observational retrospective pluricentral.

Materiel and methods

Each center of cardiothoracic surgery received a questionnaire validated by the Société française de perfusion about the activity, materials and organization used for STCRS. Data were expressed as percentages or median (25–75 percentiles).

Results

Forty-one centers on 61 (67%) answered. STCRS was performed respectively by 33 (80.5 %), 36 (87.8 %) and 39 (95.1 %) of centers in 2007, 2008 and 2009 including 10 [4–26], 18 [6–29] and 18 [5–33] cases/center per year. In 2009, types of STCRS installed were veno-arterial in 39 centres (95.1 %), veno-venous in 27 (65.9 %) and Novalung^® in four (9.8 %), including 18 [5–32], five [2–7] and 15 [1–17] cases respectively. Twenty-nine centers (70.7%) installed STCRS outside the operating theater, and 24 (58.5%) in non-cardiothoracic surgery. A mobile circulatory support unit was created in eight centers (19.5%), however 21 (51.2%) have installed STCRS externally, at distances between 10 [5–55] to 100 [15–200] km, using emergency vehicles in most of the cases (90.5%), but helicopter seldom (19%).

Conclusion

STCRS has increased over the last few years in France. Externalized activity outside the operating theater was important, time-consuming and used hospital resources therefore modifying the professional activity of perfusionists.     

Œsophagectomie carcinologique : 16 ans d’évolution des pratiques anesthésiques ventilatoires,hémodynamiques et analgésiques

Objective

To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery.

Patients and methods

We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994–2009). Statistical analysis was done on 4 chronologic quartiles of same sample size.

Results

Two hundred and seven consecutive patients were included during the 4 periods 1994–1997 (n = 52), 1997–1999 (n = 52), 1999–2003 (n = 52) and 2004–2009 (n = 51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6–10.6] vs 7.6[7.0–8.3] mL/kg of ideal body weight (IBW), p < 0.01), increased use of Positive End Expiratory Pressure (0 vs 83 %, p < 0.001) and increased use of post-operative non-invasive ventilation (0 vs 51 %, p < 0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0–24.6] vs 12.6 [9.7–16.2] mL/h/kg of IBW, p < 0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57 %, p < 0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn’t change.

Conclusions

During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed.     

Enquête nationale sur la prise en charge de la douleur aiguë postopératoire dans les hôpitaux libanais

Introduction

Postoperative pain relief in Lebanon is a public health problem because its coverage is insufficient.

Study design

A survey was performed with a questionnaire distributed to anaesthesiologists during the Lebanese national meeting of anaesthesia in May 2006.

Results

A total of 106 out of the 230 distributed questionnaires were collected. The coverage of the postoperative pain is different in the university hospitals and others. A preoperative information and postoperative evaluation of pain are only performed by 26% of anesthesiologists. A multimodal analgesia is begun in the operative room or in postanaesthesist care unit for 92% of the patients. Only 71% of the anaesthesiologists have pumps for patient-controlled analgesia. Written protocols for postoperative analgesia are available in only 58% of the centres. Among anaesthesiologists, only 36% have an initial and/or continuous formation to treat the postoperative pain. The major obstacle for improvement of postoperative pain is the cost of such treatments, which must be supported by the patients.

Conclusion

Even if there is a good awareness of the importance to relieve the postoperative pain, important efforts must be done in this domain in Lebanon.     

Comparaison de trois modes ventilatoires au cours du transport postopératoire immédiat du patient opéré de chirurgie cardiaque

Objective

Compare three ventilatory strategies during the immediate postoperative transfer of cardiac surgical patient.

Study design

Prospective, comparative and observational study.

Patients and methods

After approval by our local ethical committee, 330 patients undergoing on-pump cardiac surgery were consecutively included. Patients suffering from chronic obstructive pulmonary disease, exhibiting intraoperative hypoxemia or requiring nitric oxide were excluded. The ventilatory mode was left at the discretion of the anesthesiologist and included: controlled mechanical ventilation (FiO₂ = 1, N = 124) or (FiO₂ = 0.6, N = 106), and manual ventilation using rebreathing bag (N = 100). A blood gas analysis was performed immediately prior to connecting patient at ventilator at the arrival in ICU.

Results

The mean duration of transfer was 3.9 ± 1.4 min. Invasive pressure monitoring was used in all patients. The pulse oxymetry and electrocardiogram were respectively used in 78% and 24% of patients. PaO₂ values less than 100 mmHg and those more than 300 mmHg were more frequently found in patients ventilated by rebreathing bag (42%) and mechanical ventilation FiO₂ 1 (52%), respectively. No significant difference was found between groups regarding PaCO₂ values.

Conclusion

When rebreathing bag is used for transfer in ICU, severe decrease in PaO₂ may be observed. In absence of intraoperative hypoxemia, a mechanical ventilation with FiO₂ 0.6 seems to be the most suitable ventilatory strategy for such short immediate postoperative transfer.     

Effets de l’hydroxyzine sur l’acceptation du masque à l’induction de l’enfant

Objective

To evaluate the effectiveness of hydroxyzine as a premedication agent for the acceptance of facial mask during induction of general anaesthesia in children.

Study design

Prospective randomized single-blind study including ASA 1 and 2 children, aged between 1 and 9 years and undergoing outpatient surgery.

Patients and methods

Patients were randomly allocated to receive orally either 1 mg/kg hydroxyzine (G1) or water 0.1 ml/kg (G2) one hour before induction of standardized inhalational anaesthesia. Tolerance of facial mask was assessed with a 3-points scale (good, moderate or poor). Chi-square and Student's t-test were used in statistical analysis; p values less than 0.05 were considered statistically significant.

Results

One hundred patients were included (G1 = 49, G2 = 51). Demographic data were similar in both groups. Acceptance of facial mask was significantly better in G1 than in G2 (p = 0,002).

Conclusion

Hydroxyzine provided better acceptance of facial mask than placebo during induction of general anaesthesia in children.     

Impact clinique et économique d’une politique de contrôle de la sédation par protocole dans un service de réanimation médicochirurgicale

Objective

Since the last consensus conducted by Sfar/SRLF, the use of protocol for sedation became the reference in our ICUs. Decrease in length of stay and length of mechanical ventilation with used of these protocols have been already described. We would like to investigate the economic impact associated.

Study design

Using the PMSI data, we studied retrospectively, the economic effect, one year before and one year after protocol implementation in our ICU.

Method

The economic evaluation compared the cost of sedation but also the cost of mechanical ventilation and length of stay in ICU.

Results

Characteristic and number of patients were equivalent during the two years. We described a significant decrease in length of mechanical ventilation (8.8 vs. 8.4; p < 0.05) but not in length of stay (11.4 vs. 11.7; NS) between the two periods. We described a decrease of sedation cost of 11 412 euros and a decrease of mechanical ventilation cost of 27 360 Euros between the two years.

Conclusion

We confirm in this study that use of sedation protocol in ICU is associated with a clinical impact but also with an economic effect.     

Enquête sur la formation initiale des internes français en anesthésie locorégionale

Objective

To assess both level and type of the initial training on regional anesthesia for French residents after the publication of formalized recommendations of experts on training and practice in regional anesthesia in 2006.

Study design

Practical statement enquiry.

Material and methods

A multiple choice questionnaire was sent to all the French residents in anesthesiology. Questions are focused on demographic data (year of training, university hospital origin, theoretical training, type and length of practical courses) and regional anesthesia practice, particularly about the essentials of regional anesthesia techniques for initial training, level of practice and degree of autonomy, especially for the 5th and the 3rd years students. After sending, two follow-ups were done, responses were obtained by mail or post.

Results

The global answer rate was 29.1% (25.3% and 23.4% for the 5th and the 3rd years respectively). Concerning theoretical training, 29% of responders had anatomy course, 33% dissection and 38% a supplemental training. At the end of initial training, the official goal (30 acts for a specific technique) was achieved in 98% of cases for epidural anesthesia, 95% for spinal anesthesia, 82% for both axillary and humeral block and 72% for femoral block, with a declared 100% autonomy at this level.

Conclusion

The main goal of the formalized recommendations on training and practice in regional anesthesia is partially reached. This apparent failure can be due to both a lack of regional anesthesia exposure, inadequate faculty training, usual slavery to routine, or technical evolution of medical practice.     

Enquête de pratique sur l’analgésie péridurale en dehors de l’obstétrique

Objectives

To describe the current use of epidural anesthesia (EA) apart from obstetrics, and to explain the reasons of its low utilization.

Study design

Observational study.

Methods

A survey of practice with a self-questionnaire was sent by e-mail and available on Internet. Answers were compared between groups doing or not an epidural analgesia with exact Fisher tests (P < 0.05 statistically significant).

Results

Among the 176 anesthesiologists who answered to the questionnaire, only 21.4% never used epidural analgesia. The main reasons were alternatives therapeutics such as PCA with opioids or TAP block (24/38 vs. 46/140). TAP block was the most common alternative used by more than 50% of anesthesiologists. Loss of competence (4/30 vs. 0/39) was rarely the reason to its low utilization. The low accessibility to specialized postoperative units was recognized in both groups as a limiting factor to do an epidural but not the fear of neurological complications. Those who never perform epidural analgesia were statistically more often physicians between 40 and 50 years (12/38 vs. 19/140). Heparin, aspirin and clopidogrel are no longer contraindications according to anesthesiologists less than 40 years old (50/68 vs. 31/68; 44/68 vs. 31/68; 37/68 vs. 23/68 respectively) but not for older.

Conclusions

Epidural analgesia is performed more often by younger anesthesiologists. This survey suggests the need of specific postoperative area to allow anesthesiologist to perform and supervise safely this technique. Recommendations of the French society of Anesthesiologists are also poorly applied.     

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.     

Étude rétrospective sur six années de l’anesthésie pour réduction de luxation d’épaule en urgence

Objective

The aim of this study was to assess the anaesthetic technique used for emergency shoulder luxation management in a university hospital.

Study design

Retrospective observational study.

Patients and methods

During a six-year period, all patients who were anaesthetized for shoulder luxation were included. Data were collected from administrative database and patient's files.

Results

Two hundred and twenty-four patients were included. Ninety-seven regional anaesthesias were performed (17 failures) and so, 144 general anaesthesias were performed. Among general anaesthesia, 89 patients were not fasten, only four rapid sequence inductions were performed. Sixteen (8%) complications occurred, all during general anaesthesia, among them one inhalation. In not fasten patients, anaesthesia was performed not in accordance with guidelines in 56% of cases of all anaesthetic technique and 96% for patient who had general anaesthesia. Accordance with guidelines was independent from the anaesthesiologist experience or the time of the anaesthesia (night/day).

Conclusion

We must spread guidelines information to physicians because of the morbidity.     

Enquête nationale sur la prise en charge de l’intubation difficile en médecine d’urgence préhospitalière

Objectives

Difficult intubation rate is higher in the prehospital setting than in the operating room.Goal of this survey was to assess compliance of the French prehospital mobile emergency unit (Smur) to the recent French guidelines for the difficult airway management.

Study design

National phone survey.

Methods

A phone questionnaire was proposed to one senior emergency physician of all 380 French Smur. Seven questions were asked about intubation devices used, availability of a written difficult intubation algorithm and intubation training of the Smur's physicians.

Results

Guidelines of the recent French consensus conference on difficult intubation are only partly followed by the Smur. Only 60% of the Smur perform systematic rapid intubation sequence, plastic laryngoscope blades are used by more than 50% of the Smur and less than 50% of the Smur have a written difficult intubation management algorithm available. The Gum elastic Bougie is available in 58% of the Smur and the intubating laryngeal mask airway in 71%, whereas initial formation for difficult intubation devices used is provided to the emergency physicians in only 58% of the Smur.

Conclusion

This survey shows that the French guidelines for the difficult airway management are only partially followed by the French Smur. An effort should be made for a larger diffusion of these guidelines towards the emergency physicians working in the Smur.     

La discipline anesthésie-réanimation et les pôles d’activité médicale (PAM) : résultats d’une enquête auprès des CHU et CHG

Objective

To know: (1) how French public services of anaesthesia and critical care (ACC) have applied the new principles of hospital management and (2) whether or not it has impacted the different components of ACC.

Study design

National questionnaire at the end of 2008, i.e., after 2 years of new hospital management.

Material

Heads of ACC services in general (GH) and university hospitals (UH).

Methods

Eighteen closed questions and open opinions analyzed. Comparisons of percentages (Chi² – Yates): linear correlation.

Results

Percentages of responses were 70% (n = 51) for UH and 37% (n = 146) for GH. The new management principles were mainly applied. The different clinical and academic components of the ACC specialty (ACC, emergency medicine, pain management) mainly remained associated in UH. In GH, the new management induced constant and various changes. They were mainly judged as defeating the object of the ACC speciality in GH, especially in those of lower and mild sizes.

Conclusion

The general tendency is that the ACC specialty was able to maintain the family ties of its different components in the UH. However, this principle was not a cornerstone of the new management in the GH.     

Risque barotraumatique avec des valves de non-réinhalation de Waters : étude comparative sur banc d’essai

Objective

Manual ventilation is delivered in the operating room or the intensive care unit to intubated or non-intubated patients, using non-rebreathing systems such as the Waters valve. New generation Waters valves are progressively replacing the historic Waters valve. The aim of this study was to evaluate maximal pressure delivered by these 2 valves.

Type of study

Bench test.

Material and method

Thirty-two different conditions were tested, according to 2 oxygen flow rates (10 and 20 L/min), without (static condition) or with manual insufflations (dynamic condition) and 4 valve expiratory opening pressures. The primary endpoint was maximal pressure measured at the exit of the valve, connected to a model lung and a bench test.

Results

Measured pressures were different for most evaluated conditions. Increasing oxygen flow from 10 to 20 L/min increased maximal pressure for both valves. Increasing valve expiratory opening pressure induced a significant increase in maximal pressure for the new generation valve (from 4 to 61 cmH₂O in static conditions and from 18 to 68 cmH₂O in dynamic conditions). For the historic valve, maximal pressure increased significantly but remained below 15 cmH₂O in both static and dynamic conditions.

Conclusion

Use of new generation Waters valves should be different from historic Waters valves. Indeed, barotrauma could be caused by badly adapted valve expiratory opening pressure settings.     

Fast-tracking en anesthésie locorégionale périphérique : étude préliminaire de faisabilité

Objective

The monitoring in the postanaesthesia care unit (PACU) improves the safety, the comfort and the analgesia of patients. At present, studies suggest the possibility to bypass the PACU according to the principle of fast-tracking (FT). The aim of this study was to evaluate the feasibility and the safety of a simulated protocol of FT after a regional anaesthesia.

Patients and methods

Seven hundred patients were prospectively included in this study over a period of 6 months.

Methods

The Withes’ scoring system was used for determining when patients could be safely discharged from PACU. We added a variable concerning the monitoring of surgical site. A minimum score of 14 was required on arrival to the PACU to consider a FT. The success rate of blocks, the use of sedation or general anaesthesia were noted. Adverse events were recorded.

Results

The success rate of blocks was 93 %. The score was higher than 14 in 98 % of case on arrival to the PACU. Thirteen adverse events were reported before surgery and/or operating room. No adverse events were reported during the stay in the PACU.

Conclusion

Regional anaesthesia seems to be an appropriate principle to fast-track the PACU. It could be a way to reduce health care costs, and can offer solution for the PACU congestion problem. In France, the fast-tracking is a marginal concept without any support regulatory. An evolution to such a practice could be considered.     

Monitorage continu et automatisé de la précharge dépendance en anesthésie et en réanimation : intérêts et limites

Objectives

To describe preload dependence monitoring tools currently available as well as their limits and potential applications in the anaesthesiology setting.

Data source

References were obtained from PubMed data bank (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) using the following keywords: fluid responsiveness, cardiopulmonary interactions, preload dependence, hypovolemia, cardiac output.

Data synthesis

When measured in optimal conditions, dynamic parameters are the best predictors of fluid responsiveness as compared to static indicators in patients under general anaesthesia and mechanical ventilation. These dynamic parameters rely on cardiopulmonary interactions and allow evaluating preload dependence and the ability of the heart to transform an increase in preload into an increase in cardiac output. Recently, it is possible to monitor these dynamic parameters either invasively (from the arterial pressure waveform) or noninvasively (from the plethysmographic waveform). These tools have intrinsic limitations. However, they have potential to be used for fluid optimization during anaesthesia.