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.     

Rôle de la génétique dans la variabilité interindividuelle en anesthésie

Objective

This review discusses variability among patients in anesthesia, due to genetic polymorphisms.

Data sources

Articles in French and English languages were retrieved from PubMed database. The initial request was “anesth* and (genotyp* or polymorphism* or genetic*)”.

Study selection

Original articles, general reviews and one case report. Letters were excluded.

Data extraction

Rare genetic diseases were excluded from the scope of this review. We stressed on frequent genetic polymorphisms that may have a daily impact in anesthesiology.

Data synthesis

Most results were related to pain studies. We selected various examples to describe how genetic polymorphisms impacts the pharmacology of a given drug, and what are the clinical consequences.

Conclusion

There is a growing field of pharmacogenetic related evidences in anesthesiology. The results from various animal and human studies underline the genetic origin of variability among individuals. How anaesthesists have to integrate these parameters for their daily practice is still unclear, but pharmacogenetic will obviously be a leading field of anesthesia research in the future.     

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.     

Évaluation de l’utilisation du sulfate de magnésium dans la prévention secondaire de l’éclampsie : étude rétrospective sur 39 cas

Introduction

The use of magnesium sulfate (MgSO₄) has been advocated since 2000 in France in the management of eclampsia. The aim of this study was to determine the frequency of use of this treatment for eclampsia in a French department.

Patients and methods

All patients obstetrical patients admitted to Critical Care Units of Seine-Maritime for eclampsia over a period of 7 years (2002–2008) were included. Obstetric data, the treatment used for eclampsia and pre-eclampsia and maternofetal complications were collected. The primary outcome parameter was the use of MgSO₄ in the secondary prevention of eclampsia.

Results

Thirty-nine patients were included. Nineteen patients (48%) had eclampsia in prepartum, three (8%) in per-partum and 17 (44%) in post-partum periods. The use of MgSO₄ in the secondary prevention of eclampsia was observed in 92% of cases (36/39). Primary prevention was seen in 8% of cases. The duration of treatment was 2 days (1–7 days). The maternal and perinatal mortality was respectively 2.5 and 11%.

Conclusion

In this study, the use of MgSO₄ in the secondary prevention is frequent. This result emphasizes the importance of the recommendations of learned societies in the homogenization of the management of rare but serious conditions such as eclampsia.     

Enquête sur l’évaluation et la prise en charge nutritionnelle des patients adultes cirrhotiques candidats à une transplantation hépatique

Objective

The European Society for Clinical Nutrition and Metabolism (EPSEN) guidelines on nutrition for liver disease patients has been recently updated. The aim of our study was to evaluate perioperative nutrition in cirrhotic patients waiting for liver transplantation (LT).

Study design

Prospective electronic survey. A standardized questionnaire was sent to the anaesthesiologist of the 18 French adult LT centers. The questionnaire had closed-ended questions to evaluate nutritional practices in cirrhotic patients waiting for a LT.

Results

The response rate was 100%. Nutritional status of the cirrhotic patients waiting for LT was assessed by anaesthesiologists (12 centres) and/or hepatologists (11 centres) and more rarely by nutrition physician, dietetics or liver surgeons. Body mass index (13 centres), weight loss (10 centres), albuminemia (10 centres) were the most frequent items used to assess the nutritional status. Before LT, preoperative oral intakes were administered in undernourished patients in only 55% of the cases. Postoperatively, nutritional support was administered between day 1 and 3 after LT.

Conclusion

Perioperative nutritional practices in cirrhotic patients waiting for LT are heterogeneous between centers, especially about nutrition assessment. Most of the centres did not follow the actual guidelines.     

Transfusion sanguine en opération extérieure. Expérience à l’hôpital médico-chirurgical de Kaboul

Objectives

Blood transfusion is an aspect of medical care on the battlefield. French assets include: red blood cell units (RBCu), lyophilized plasma (PLYO), fresh whole blood (FWB) but neither fresh-frozen plasma (FFP) nor platelets. French transfusion strategy in military operations follows the evolution of knowledge and resources. We describe the characteristics of the transfusion at the military hospital in Kabul.

Patients and methods

Retrospective study of records of patients transfused between October 2010 to December 2011 conducted in Kabul from transfusion register. Variables studied were: patient characteristics, biology at admission, type and amount of transfusion products, evolution.

Results

One hundred and twenty-six patients were transfused: 49 military (39%) which 22 French soldier (17%), most of time afghan (n = 97; 77%), mean age at 24 years old (3–66). Two hundred and seventy-three RBCu from France were transfused and 350 unused were destroyed. Conditions leading to a transfusion were: 76 war wounds (60%), 21 trauma (17%) and 29 other (23%). In the first 24 hours, patients received in mean: two RBCu (0–12), one unit of FWB (0–18) and two PLYO (0–14). PLYO/RBCu ratio was 1/1.6. A massive transfusion (more than 10 RBCu) concerned 9% of patients. Twenty-seven percent of patients received FWB. We note 17 dead people (13.5%).

Conclusion

The use of the FWB and PLYO in substitution of FFP and platelets can provide cares of high quality in a logistically constrained context while controlling costs.     

Impact de la diminution d’utilisation du protoxyde d’azote sur la consommation d’agents halogénés

Objective

Nitrous oxide (N₂O) toxicity and its impact on pollution lead to restrict its use. A decrease of N₂O consumption should increase the hypnotic inhaled consumption. This monocentric study estimated consumptions and costs of halogenated agents (HA) and N₂O over 5 years when the N₂O consumption was reduced.

Study design

Retrospective from a computerized database.

Patients

Between 2006 and 2010, 34,097 procedures were studied after two meetings exposing the risks of the N₂O.

Methods

At the end of anesthesia, consumptions of hypnotic agents (millilitres transmitted by the injectors and the blender) were archived in the database. The annual consumption of agents was obtained by adding the individual consumptions, then divided by the annual number of cases. The costs were given by the hospital pharmacy from invoices.

Results

N₂O consumption per anesthesia constantly decreased during the study, from 75.1 L by act to 22.7 L. The sum of the annual consumptions of N₂O and air did not change suggesting that total fresh gas flow remained stable. Between 2006 and 2010, the sevoflurane consumption by act increased by 25%, from 16.5 to 20.6 mL, and desflurane consumption by 37%, from 46.1 to 63.1 mL by patient. The costs of the administration of hypnotic agents remained stable.

Conclusion

N₂O consumption decrease had an impact on the consumption of HA. The cost reduction of the N₂O was counterbalanced by the increase of halogenated vapor cost. The profit of the ecological impact of the reduction in N₂O use could be quantified.     

Gestion de la glycémie : un audit dans 66 réanimations

Introduction

The interest of tight glucose control in ICU is still debated. In France, no data are available regarding this therapy and the implementation of its guidelines.

Study design

Sub-study of a one-day audit performed between January and May 2009.

Patients and methods

During a one-day audit performed in 66 ICUs, trained residents collected data regarding the presence of a formal glucose control protocol and its practical application.

Results

A formalized glucose control protocol was found in 88% of patients. During the day before the audit, 3645 glycemia measurements were performed accounting for six measurements [4–9] per patient with a median higher value of 1.6 [1.4–2.1]. Hypoglycemia (< 0.8 g/L) and hyperglycemia (> 1.4 g/L in non-diabetic and > 1.8 g/L in diabetic patients) were found in 81 (15%) and 326 (58%) patients respectively. Two episodes (0.36%) of severe hypoglycemia (< 0.4 g/L) were reported. Factors associated with glucose control protocol application were: a high SOFA score, cardioversion, mechanical ventilation, intracranial pressure monitoring, steroid use and nurse to patient ratio less than 1/2.5. Hepatic failure was the only factor associated with hypoglycemia.

Discussion

Glucose control protocols are available in more than 80% ICUs but their implementation is still imperfect. However, the median glycemia meets international current recommendations. Severe hypoglycemia is a very rare event in ICU.     

Transfusion de sang frais total en temps de guerre : expérience du groupement médicochirurgical Warehouse durant la période 2006–2009

Objective

The specificities of military medicine have led to the maintenance of fresh whole blood (FWB) transfusion.

Study design

The aim of our study was to evaluate this practice at the French military hospital in Kabul between 2006–2009.

Patients and methods

During our study period, 19 FWB transfusions were performed and the data from 15 FWB transfusions could be analyzed. We studied the number of units by recipient, the characteristics of recipients, the results of blood tests performed after transfusion, the incidents in donors and recipients, the period for obtaining a unit of FWB and mortality of recipients.

Results

A total of 66 units of FWB were transfused in 15 patients. The median number of FWB units transfused was three per patient. Thirteen out of 15 (87%) were combat-related casualties. All units were tested before transfusion for HIV with rapid diagnostic tests. Every blood samples of donors were negative for pathogens screened at the French Blood Service. No incident in donors and in recipients was reported. The average time between collection and transfusion was 140 ± 197 minutes (median 43 min). Mortality in recipients was 27% (n = 4).

Conclusion

In our study, the FWB transfusion was not associated with incidents. Nonetheless, this practice should be used only for exceptional situations like military conflicts where risks of FWB are lower than the absence of transfusion.     

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.     

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.     

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.     

Réhabilitation précoce après césarienne programmée : enquête de pratique auprès des maternités des régions Provence - Alpes - Côte d’Azur et Île-de-France

Aims

Although most components of an enhanced recovery programme (ERP) can be applied to caesarean delivery, it is unknown if their implementation is large in France.

Type of study

Structured interview by telephone or e-mailing of an anaesthetist to describe usual perioperative practice in two French regions (Provence - Alpes - Côte d’Azur [PACA] and Île-de-France [IDF]).

Methods

Questionnaire related to scheduled caesarean delivery.

Results

Response rate 74% (111/149 maternity units). Multimodal analgesia was almost universally applied and intrathecal/epidural morphine used by 86% of respondents. Oral administration of analgesic drugs was started before h24 in 50% of responding units and immediately after delivery in 7% of them. The urinary catheter was withdrawn after h24 in 71% of responding centres. Women were allowed to drink between h4 and h6 (60%), in an unlimited amount (79%). The first meal was authorised after h6 (89%) but before h24 (65%) or after recovery of bowel function (13%). Oxytocin was used in 69% of respondents and maintained postoperatively for 12 to 24 hours (70% of oxytocin users). Carbetocin was used in the remaining 31%, usually without any maintenance oxytocic drug. Attributing one point to each major component of the ERP protocol (0–6), the median value was 3 (2–4). An ERP protocol was available in 14% of responding units and was associated with a shorter duration of intravenous and urinary catheters use.

Conclusion

The study shows that the components of an ERP are insufficiently implemented in France after caesarean delivery. Moreover, significant heterogeneity exists between maternity units and among regions.     

Venous oximetry: physiology and therapeutic implications

Objectives

The aims of this review are to point out the determinants of oxygen saturation of the haemoglobin of mixed venous blood (SvO₂), to specify the correlations existing between SvO₂ and central venous saturation in superior vena cava (ScvO₂), to determine and finally to locate the current place of venous oximetry in clinical practice.

Data sources

A PubMed^® database research in English and French languages published until December 2006. The keywords were mixed venous blood oxygen saturation; oxygen consumption; oxygen delivery; oxygen extraction; tissue hypoxia; central venous oxygen saturation.

Data extraction

Data in selected articles were reviewed, clinical and basic science research relevant information was extracted.

Data synthesis

The SvO₂ reflects the peripheral extraction of oxygen (O₂), O₂ delivery and consumption. Its value is related to four determinants: the O₂ consumption (VO₂), cardiac flow (CF), haemoglobin level (Hb) and O₂ saturation of the haemoglobin of arterial blood (SaO₂). ScvO₂ is more easily measurable than SvO₂. Under physiological conditions its value is 2 to 3% lower than that of SvO₂. In the critically ill patient, its value is 5% higher than that SvO₂. In most patients, changes in ScvO₂ values parallel those in SvO₂. The clinical interest of the monitoring of venous oximetry was underlined in cases of severe sepsis and septic shock, and during the perioperative period of major surgery.

Conclusion

The management of patients in critical states with therapeutic goals integrating the monitoring of venous oximetry may reduce the morbidity and mortality of patients undergoing major surgery or hospitalised in the intensive care unit.     

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.     

La préhabilitation. Préparer les patients à la chirurgie pour améliorer la récupération fonctionnelle et réduire la morbidité postopératoire

Objective

Prehabilitation consists in providing a repetitive physical exercise before surgery to improve the postoperative recovery course. This review aims to evaluate the feasibility and the expected benefits of prehabilitation on the postoperative recovery course and the reduction of the postoperative morbidity.

Data sources

Data research has focused on English-language articles in the Medline database, published from 1989 to 2013. Keywords, used separately or in combination, were: prehabilitation, functional capacity, postoperative morbidity, physical activity.

Study selection

Selected articles were original articles, clinical cases, review articles and meta-analysis.

Data extraction

Articles were analyzed for feasibility, benefits and limitations of preoperative physical preparation techniques.

Data synthesis

Poor preoperative functional status is associated with increased postoperative morbidity. Elderly are more prone to postoperative complications. The improvement of preoperative physical status of these patients is possible and may reduce morbidity and allow faster recovery after major surgery. In order to improve efficiency, the training program must provide endurance and muscle reinforcement exercises, whose intensity must be adapted to the patient's baseline physical abilities. An average of three sessions per week over a period of six to eight weeks before surgery seemed a good compromise between feasibility and effectiveness.

Conclusion

The effectiveness of prehabilitation has been demonstrated in cardiovascular surgery and probably in abdominal surgery. Prehabilitation must be integrated into the overall patient medical management, and must be associated with preoperative refeeding and postoperative rehabilitation protocols. By optimizing all stages of the surgical patient management, from diagnosis to recovery, prognosis of high-risk surgical patients could be improved.