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.     

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.     

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.     

Utilisation du masque laryngé : une enquête nationale de pratique professionnelle

Background

This survey aimed to describe the current use of laryngeal mask (LM) and to define the difference of use according to a group defined like experts.

Methods

A self-questionnaire available on Internet was sent by e-mail to French anesthesiologists. Results were compared by a Chi² test between anesthesiologists according to their expertise defined by a >750 LM use.

Results

Nine hundred and fifty-three anesthesiologists answered to the survey. Only 19 reported never using LM and 37% of responders were defined as expert. More than half of the MAR used the ideal weight to set the size of the MLA to use. Pressure leak was sought by less than one-third of the MAR. In case of leakage, a mobilization of the ML or the patient's head was performed first. In second intention, nearly a quarter of MAR changed technique for the benefit of oral intubation. Only 50% of responders used LM as a rescue technique in case of difficult intubation and ventilation. Experts had less insertion failure and laryngospasm. Complications and medico-legal suites are few.

Conclusions

Variability of practice may be explained by low-grade recommendations in the literature. LM insertion in case of difficult intubation/ventilation to provide adequate oxygenation and should be formally reminded to clinicians.     

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.     

Intérêt de l’anesthésie péridurale cervicale dans la gestion périopératoire d’une thyroïdectomie chez une patiente à haut risque anesthésique

Cervical epidural anesthesia is an anesthetic technique that can be useful in patients with high perioperative risk undergoing to cervical surgery. We report the case of a patient of 49 years old with hypertension, diabetes mellitus, epilepsy, left hemiparesis sequelae of stroke and congestive left ventricular failure. The patient underwent total thyroidectomy under cervical epidural anesthesia. No difficulty breathing or decompensation of chronic underlying diseases were noted in the postoperative.     

Consentement éclairé en anesthésie pédiatrique pour les soins courants et pour la recherche

This short review is aimed at describing the particularities of consent in paediatric patients. For routine procedures, the consent of one of the parents is required whereas both parents should sign the consent for research protocols. In case of difficulties such as Jehovah witnesses or parental opposite opinions, doctors should ask the question to the judge in charge of protection of children. Consent or at least assent of minors enrolled in research protocols should be obtained provided their maturity is sufficient to understand correctly the purpose of clinical research.     

Réhabilitation périopératoire des césariennes programmées non compliquées en France : enquête de pratique nationale

Introduction

Enhanced recovery is a concept currently recognised and adopted in a number of surgical specialties. In obstetrics however, this concept remains surprisingly underdeveloped. The purpose of this survey was to study the practice of obstetric anaesthetists in France as regards the recovery of women undergoing uncomplicated, elective caesarean section.

Material and method

An online 39-point questionnaire was displayed for 2 months on the Caro (Club d’anesthesie réanimation en obstétrique) website. The questionnaire related to uncomplicated, elective Caesarean sections and aimed to define the following: preoperative information given regarding the recovery period, intraoperative care – both anaesthetic and surgical, postoperative analgesia, measures taken to prevent post-partum haemorrhage, reintroduction of fluids and diet, return to mobility, local practices designed to promote bonding between mother and baby.

Results

The overall response rate for our survey was 45%. Forty-nine percent of practitioners report that patients are provided with specific information on the recovery period preoperatively. Sixty percent of those surveyed state the absence of any specific recovery protocol for this patient population in their hospital. Eighty-one percent of respondents state that, in the majority of cases, patients are admitted on the eve of surgery and remain hospitalised for more than 72 hours (89%). Ninety-nine percent of practitioners employ a regional technique to deliver anaesthesia for elective section and 44% rely on intrathecal morphine for postoperative analgesia. The concept of ‘Patient Controlled Oral Analgesia’ (PCOA), although widely recognised, is used by only 17% of practitioners. Forty-one percent of practitioners report the reintroduction of fluids as soon as patients return to the ward following surgery and at the same time as the urinary catheter is removed (51%). Diet is commenced 4 to 6 hours following surgery amongst 40% of those surveyed. Fifty-one percent of practitioners report removal of the intravenous catheter 24 hours postoperatively. Finally, 49% of practitioners feel patients are independently functioning and mobile within 24 hours of surgery.

Conclusion

This survey of national practice shows that the concept of ‘enhanced recovery’ following elective caesarean section can be again developed. Standardisation of practice with the design of local protocols relating to postoperative analgesia, timing of removal of the intravenous access and urinary catheter, time to first mobilisation and to commencement of diet would appear to be warranted. Surely this surgery, more than any other, merits an expeditious and effective return to normal and independent function, allowing mother to better look after baby.     

Analgésie péridurale obstétricale et maladie de Willebrand de type 2B

Type 2B von Willebrand disease (vWD) is an inherited bleeding syndrome resulting from a qualitative abnormality of von Willebrand Factor with an increased affinity for the glycoprotein Ib platelet receptor. Pregnancy increases the severity of this disease by decreasing the platelet count restricting epidural anaesthesia because of adverse risk of spinal bleeding. There is a phenotypic variability of Type 2B vWD depending of the von Willebrand Factor mutation. We report here the strategy we used to administer epidural anaesthesia for a patient with Type 2B vWD resulting from the P1337L mutation of von Willebrand Factor.     

Une complication de l’anesthésie péridurale : la rupture d’un cathéter

We report the breaking of an epidural catheter, which occurred during the procedure of insertion. If such a breaking is a rare event, it is due in this case to an aberrant trajectory of the catheter. By studying the literature, we also analyzed the mechanisms which can lead to the breaking of an epidural catheter. We recommend a precise radiological examination to localise the trapped catheter among the nervous structures.     

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.     

Syndrome de Parkes-Weber et grossesse : implications anesthésiques

We report two deliveries in a patient with a Parkes-Weber syndrome. This parturient had a complex angiodysplasia including a soft tissue hypertrophy of a lower limb, a cutaneous angioma and arteriovenous malformations. The risk of perimedullar arteriovenous malformations was ruled out by angiographic magnetic resonance imaging of the spinal cord. We also describe other aspects of the management, including prepartum cardiovascular assessment, mode of delivery, the use of epidural analgesia and the prevention of haemorrhagia and thromboembolism.     

Organisation de l’anesthésie des enfants dans un hôpital non pédiatrique

The author reviews the guidelines and the possible organization of anaesthesia and surgery in a non-paediatric hospital.