Incidences et causes d’insatisfaction des patients vis-à-vis de la prise en charge de la douleur postopératoire

Introduction

Patient satisfaction regarding postoperative pain management (POPM) is not always correlated with pain level relief.

Objective

To evaluate the percentage of satisfied patients while splitting satisfaction related with nurses, anaesthesiologists and surgeons during 48 h postoperative period.

Patients and methods

The study was performed in 2007 by two investigators in six different surgical suites in a university hospital. Approximatively 15 patients have been randomly selected in each surgical ward. Each patient received during the first or second postoperative day an anonymous questionnaire and was required to complete it with the investigator assistance if necessary. Questions requiring a yes-or-no reply assessed the patient's satisfaction with POPM performed by nurses, surgeons, and anaesthesiologists. In case of dissatisfaction, patients were invited to explain the reasons.

Results

Ninety-two patients were included, 5% of the patients were not satisfied with nurse POPM and nearly 15% were not satisfied with anaesthesiologist or surgeon POPM. The main reasons of dissatisfaction with nurses were the excessive delays between requesting and receiving an analgesic and because of the significant discrepancies in POPM between nurses. Patient discontent regarding surgeons was explained by the lack of interest of the latter for POPM. Patient discontent regarding anaesthesiologists was explained by the lack of anaesthesiologist visit in the postoperative period.

Conclusion

There is a relationship between patient dissatisfaction and the lack of attention for POPM by surgeons and the lack of postoperative visit by the anaesthesiologist. A postoperative visit by a team of anaesthesia nurses should improve patient satisfaction with POPM.     

Définitions et conséquences des hypertensions artérielles de la grossesse

Hypertensive pathologies during pregnancy lack definition. Meanwhile, we can offer the following definitions:

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Gestational hypertension (GHT): Systolic HT ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Which occur beyond the 20th week of amenorrhea and fading before the 42nd day postpartum.     

Effets de la lidocaïne sur la circulation artérielle et veineuse des membres chez l'homme

The effects of intravenous lidocaine on limb arteries and veins were investigated in a placebo-controlled study. Seven young healthy volunteers, 23 to 28 — years — old, were included. Electrocardiogram, arterial pressure and arm and leg blood flows were recorded continuously. Systolic and diastolic blood pressures were measured in the left arm by finger photoplethysmography. Limb blood flow and the limb venous system were studied by venous occlusive plethysmography. The venous parameters studied were venous tone, lowest closing pressure, venous volume at 30 mmHg, and venous distensibility. After an initial bolus of 1.5 mg · kg⁻¹ lidocaine had been given, 30, and then 60, μg · kg⁻¹ · min⁻¹ were given for one hour each. Plasma noradrenaline and serum lidocaine titres were measured before giving the lidocaine, and at the end of each one hour period. Placebo consisted in a two hour infusion of 0.25 ml · min⁻¹ normal saline. Lidocaine titres were 1.64 ± 0.40 μg · ml⁻¹ after one hour, and 2.55 ± 0.69 μg · ml⁻¹ after two hours. Lidocaine increased vascular resistances in both the forearm (+ 81 % to + 93 %) and the calf (+ 38 % to + 57 %). There was a concomitant increase in mean arterial blood pressure (+ 21 % to + 28 %) without any change in heart rate. There was a significant dose-dependent increase in plasma noradrenaline levels during the second period of the lidocaine infusion with respect to the preinfusion period and the same period during the placebo infusion. Venous capacitance measured before any infusion had been started was greater in the leg than in the arm. Lidocaine induced a progressive increase in forearm venous tone, which became significant during the period of higher infusion rate. There wasn't any change in calf venous tone. It would therefore seem that the arterial and venous effects of lidocaine which have been reported may be due to an increase in adrenergic tone. The vascular effects of therapeutic serum levels of lidocaine may contribute to the good cardiovascular tolerance of this drug, both as local anaesthetic agent, and as antiarrhythmic drug.     

Description de la prévention et estimation de la fréquence des erreurs de programmation de vitesse d’administration en continu des médicaments en réanimation par une application informatique

Objectives

To assess the usefulness and the feasibility to use a software supervising continuous infusion rates of drugs administered with pumps in ICU.

Study design

Follow-up of practices and inquiry in three intensive care units.

Material

Guardrails software^TM of reassurance of the regulations of the rates of pumps (AsenaGH^TM, Alaris).

Methods

First, evaluation and quantification of the number of infusion-rates adjustments reaching the maximal superior limit (considered as infusion-rate-errors stopped by the software). Secondly, appreciate the acceptance by staffs to such a system by a blinded questionnaire and a quantification of the number of dataset pumps programs performed with the software.

Results

The number of administrations started with the pumps of the study in the three services (11 beds) during the period of study was 63,069 and 42,694 of them (67.7 %) used the software. The number of potential errors of continuous infusion rates was 11, corresponding to a rate of infusion-rate errors of 26/100,000. KCl and insulin were concerned in two and five cases, respectively. Eighty percent of the nurses estimated that infusion-rate-errors were rare or exceptional but potentially harmful. Indeed, they considered that software supervising the continuous infusion rates of pumps could improve safety.

Conclusion

The risk of infusion-rate-errors of drugs administered continuously with pump in ICU is rare but potentially harmful. A software that controlled the continuous infusion rates could be useful.     

Apport de la microponction articulaire des doigts et des orteils au diagnostic rhumatologique

Objectives. To assess the diagnostic usefulness of digit joint aspiration in patients with involvement of one or more digit joints. Patients and methods. All patients who underwent digit joint aspiration during a rheumatology outpatient visit between 1994 and 1998 were included. Fine needles (25 or 28 G) were used, and the aspirate was immediately examined under the microscope to determine the leukocyte count and to look for crystals under polarized light. Results. Digit aspiration yielded a diagnosis of crystal deposition arthropathy in 20 (29%) of the 71 patients (gout, N = 14; calcium pyrophosphate dihydrate crystal deposition disease, N = 6). In 28 patients, the amount of fluid was too small to allow analysis. The leukocyte count indicated inflammatory disease in eight of the remaining 23 patients and mechanical disease in 15. Conclusion. Fine-needle aspiration of symptomatic digit joints provided the diagnosis in two-thirds of patients.     

Amélioration de la perfusion des organes vitaux par la valve d’impédance inspiratoire et le concept de pompe respiratoire : rationnel physiologique et application clinique

Objective

In this article, we review the effects of the respiratory pump to improve vital organ perfusion by the use of an inspiratory threshold device.

Data sources

Medline and MeSH database.

Study selection

All papers with a level of proof of I to III have been used.

Data extraction

The analysis of the papers has focused on the physiological modifications induced by intrathoracic pressure regulation.

Data synthesis

Primary function of breathing is to provide gas exchange. Studies of the mechanisms involved in animals and humans provide the physiological underpinnings for “the other side of breathing”: to increase circulation to the heart and brain. We describe studies that focus on the fundamental relationship between the generation of negative intrathoracic pressure during inspiration through a low-level of resistance created by an impedance threshold device and the physiologic effects of a respiratory pump. A decrease in intrathoracic pressure during inspiration through a fixed resistance resulting in an intrathoracic pressure of −7 cmH₂O has multiple physiological benefits including: enhanced venous return, cardiac stroke volume and aortic blood pressure; lower intracranial pressure; resetting of the cardiac baroreflex; elevated cerebral blood flow oscillations and increased tissue blood flow/pressure gradient.

Conclusion

The clinical and animal studies support the use of the intrathoracic pump to treat different clinical conditions: hemorrhagic shock, orthostatic hypotension, septic shock, and cardiac arrest.     

Enquête française sur la prise en charge de la circulation extracorporelle et la formation des perfusionnistes en 2008

Introduction

Cardiopulmonary bypass (CPB) is a medical act that can be performed by nurses as long as they are constantly supervised by a physician. No initial formalized training course is required. The personal responsibilities of nurses and physicians about CPB have not been defined.

Objectives

The purpose of this study was: to list perfusionists; to evaluate the training of perfusionists; to determine which physicians are considered as in charge during actions performed by paramedics, as well as their qualification; to point out the changes since 1997.

Type of study

Professional practice assessment.

Methods

A questionnaire was sent to all perfusionists in activity in France.

Results

There were 71% of replies. We found an aging of perfusionists (median 49 years vs. 40 years in 1997), a fall in the proportion of trained physicians (13% of perfusionists had a training course in adequacy with professional guidelines, 25% of perfusionists said they worked with a physician who could intervene at all time, and 61% declared only one physician was in charge). There is no CPB referent in 26% of perfusion units.

Conclusion

An urgent need appears to define the respective responsibilities of medical and paramedical perfusion staff, especially as this technique spreads out of the conventional cardiac surgery operating theatres.     

Comparaison prospective et randomisée de la morphine nébulisée versus la péridurale thoracique dans la prise en charge de la douleur des traumatisés thoraciques

Introduction

Successful management of pain reduces morbidity and improves patient satisfaction of patient after a chest trauma. The purpose of the study was to evaluate the efficacy of the respiratory administration of nebulized morphine in such patients.

Patients and methods

Patients were included in this prospective and randomized study patients to receive either nebulized morphine in group M or a mixture of bupivacaine-fentanyl by epidural route. In group M, patients received nebulized morphine every 30 minutes until the second hour then every 4 hours during 48 hours. In the thoracic epidural analgesia group (group P) they received a mixture of 0.125% bupivacaine and 0.115% of fentanyl continuously infused at the rate of 7 ml/h during 48 hours. The main criterion of judgment was the analgesic effects of analgesic regimen with EVA < 4. Sedation, haemodynamic and respiratory parameters were continuously recorded, as adverse side effects were they occurred. Statistical comparisons were performed with Chi², Fisher or Student t-test when appropriate (p < 0.05).

Results

Forty patients were randomized in two groups. Groups were not different regarding the demographic parameters. Analgesia was effective in both groups (NS). Sedation, hemodynamic and respiratory parameters were not different between groups. No side effect was noted in groups.

Conclusion

Nebulized morphine was an analgesic technique as effective as epidural bupivacaine-fentanyl in our series. This non-invasive route of administration of morphine appears to be useful to treat pain after a chest trauma.     

Évaluation des pratiques professionnelles de la prise en charge de la douleur postopératoire à court,moyen et long terme

Objectives

To evaluate the short medium and long-term impact of a quality-improvement program (QIP) in a university hospital using a validated reference tool.

Methods

Seven surgical departments were audited before and after implementation of a QIP in postoperative pain management. Audits were conducted in 2005, 2007, 2009 and 2012. In each audit, 10 medical charts from each surgical department were analyzed for 9 quality criteria. A surgical department score (SDS) was calculated for each department (maximum score = 90). The surgical departments with a SDS < 45 received targeted training sessions.

Results

In 2005, three surgical departments had a SDS < 45. After the first audit, a targeted training sessions was conducted in the three surgical departments, all seven departments improved their scores with a SDS > 45 in 2007. Between 2007 and 2009, all seven departments improved their scores. Conversely, between 2009 and 2012, the SDS diminished in six of the seven surgical departments and four of the nine evaluated quality criteria decreased significantly: right detailed order for postoperative pain analgesia (prescriber identifier, agent used, unit doses, mode of administration; 100% versus 53; P = 0.027), appropriate dosing of steps I and II analgesics (96% versus 80%; P = 0.041), morphine (90% versus 76%; P = 0.039), based on corresponding physician orders and monitor morphine side effects (87% versus 29; P = 0.027).

Conclusion

Audits should be performed regularly (at least every two years) for detecting postoperative pain management degradation. Lack of targeted training sessions can explain partially this degradation.