Treatment of iron deficiency in predialysis state by low molecular weight iron dextran high doses intravenously

Anemia is a common complication of chronic kidney disease (CKD) in predialysis stage. Iron deficiency is more common than in normal patients and plays a key role in the genesis of anemia. Its correction avoids the use of erythropoiesis stimulating agents (ESA) or reduces their dosage. Treatment with oral iron is often poorly tolerated and ineffective, necessitating the use of intravenous iron. New forms of injectable iron allow the use of high doses and correct iron deficiency in a single administration with consequent preservation of venous capital and lower costs. We studied the effectiveness of iron dextran of low molecular weight (LMWID) in high doses to correct iron deficiency and treat anemia in predialysis CKD patients. Twenty-nine doses of 500 to 1600 mg were administered to 25 patients followed for CKD (GFR between 60 and 10 ml/min per 1.73 m²), selected on biological criteria of iron deficiency defined by a ratio of transferrin saturation (TSAT) < 20% and/or serum ferritin of less than 100 μg/L. Patients received treatment by ESA in 16 cases out of 29. One month after treatment, hemoglobin (Hb) increased significantly (11.4 ± 1.6 vs 10.4 ± 1.4 g/dL, P = 0.0003) along with a significant increase in TSAT (21.3 ± 7.3 vs 13.3 ± 3.8%, P = 0.000003) and serum ferritin (286 ± 253 vs 91 ± 60 μg/L, P = 0.00005). Six patients had a serum ferritin greater than 500 μg/L after treatment, which may put them at risk of iron overload. Their serum ferritin was higher than the rest of the population before treatment, while the TSAT was no different, reflecting a functional deficiency. Their hemoglobin did not increase after treatment in contrast to the rest of the population suggesting the unavailability of iron for erythropoiesis with accumulation in the reticuloendothelial system. Renal function did not change significantly and there were no cases of acute renal failure. No immediate side effect was observed. Three patients presented delayed reactions to such self-limiting myalgia and arthralgia. No venous inflammatory reaction was noted. The administration of high doses of LMWID is effective in treating anemia of CKD in the predialysis stage with a satisfactory tolerance, without affecting kidney function and helps preserve the venous capital. It should be reserved for patients whose serum ferritin is less than or equal to 150 μg/L.     

Syringe drug labels: a French national survey

Introduction

The French Society of Anaesthesiology (SFAR) recommends the use of pre printed self-stick syringe labels. However, French anaesthesia-syringe labelling customs is yet unknown.

Study design

Therefore, a national phone survey was performed in order to investigate this issue.

Results

Forty-five percent of the answering centers (324/722) used colour self-stick labels, with a larger proportion in public centers and a large regional variability. The kind of colour code differed from an area to another. Among centers using colour labels, the international recommended colour code was used in only 36% of them. The majority of health care providers declare to be favourable to the use of the colour self-stick labels and the standardization of the colour code as well. A relationship between the University hospital and the surrounded area has been observed for the use of the colour labels and the choice of the colour code.

Conclusion

Colour labels are used in France by nearly half of the centers, but international colour code is less spread.     

Medical handovers in ICU: a snapshot of practice in the South West of France

Introduction

Medical handover is critical for quality of care in ICU. Time assigned to medical handovers can vary across different units, with significant impact on the organization of medical work. We aimed to study the time spent for medical handover in ICU and its variation across academic, general and private hospitals in the area of the South West of France, the Midi-Pyrénées region.

Methods

Between August and October 2010, we questioned by phone, 86 physicians issued from 19 different ICUs. This prospective observational study mainly focused on four items: unit's characteristics, health diaries organization, medical handovers procedures, and self-assessment of satisfaction for medical handover (numeric scale from 0 to 10).

Results

Eleven general hospital centers, three private hospitals, five university hospitals were concerned by the survey. The mean time spent for medical handover was 59 ± 35 min on monday morning, significantly longer than other days, evening, and to weekend handovers (P < 0.001 for all comparisons). When reporting it to the number of ICU bed, the time spent for handover per patient was significantly shorter in private hospital compared to general and academic hospital (P < 0.05 for all comparison).

Conclusion

Time spent for medical handover is important, with an approximate total time of 1 h 30 min on monday, and 1 h the other days. Physician in private hospitals spend less time for medical handovers. This fact should be considered for medical timework organization, especially in academic hospital and in hospital with large ICU.     

Watermelon stomach: a rare cause of iron deficiency anemia, surgically treatable; a new case with review of the literature

The authors report a new case of water-melon stomach, without portal hypertension, and responsible for a iron deficiency anemia cured by antrectomy. Water-melon stomach is a particular form of gastric antral vascular ectasia, characterized by a specific and striking endoscopic aspect. The diagnostic, histologic, pathogenic and therapeutic aspects are reviewed.     

Field 4. Environmental safety practice in the intensive care unit. French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation

Medical devices are known to carry risks from design to scrap. Accident reports in ICU show that medical device account for only 20% of accidents. Formation of users and providing a postmarketing incident reporting are thus essential in health institutions. Clinical and engineering departments should cooperate to produce and secure procedures which should be applied during the lifetime of each clinical device. Several points should be especially fulfilled: close cooperation between clinical departments and biomedical engineering departments with available technicians, computer-based inventory of all devices, evaluation of specifications required before purchasing a new device, education of users on utilisation and maintenance, technical follow-up of devices and keeping maintenance and repair logs, ability to provide users with replacement devices, provision of check-lists before use, forging criteria to decide when device should be discarded. These principles are simple and should be considered as mandatory in order to improve medical device related security.     

The sitting position in neurosurgical anaesthesia: a survey of French practice

INTRODUCTION: It remains a French and international controversy about the use of the sitting position in neurosurgery. The aim of this study was to evaluate the frequency of sitting position use, perioperative monitoring and procedures for air embolism detection and treatment. STUDY DESIGN: National postal survey. PATIENTS AND METHODS: The survey was sent in may 2000 to the anaesthesiologists in 53 french public neurosurgical centers. Responses were collected during 9 months. RESULTS: Among the 44 centers (83%), 33 (75%) used the sitting position. In 20 centers (61%) it was limited for the surgical procedures for which the surgeon was unable to operate in other position. Perioperative monitoring for air embolism was: capnography (100%), Swan-Ganz catheter (21%), precordial Doppler ultrasonography (15%) and transoesophageal echocardiography (6%). Only 12 centers (36%) used 2 or more techniques of detection for perioperative air embolism. In the 25 centers (76%) of those, which used the sitting position systematic pre-operative identification of patent foramen ovale by contrast echocardiography was performed. Prevention procedures of air embolism were: plasma volume expansion (94%), antigravity suit (61%), mechanical ventilation with positive end-expiratory pressure (42%), and abdominal compression (24%). No protocol of air embolism prophylaxis was used in 18 centers. CONCLUSION: The survey concerned 83% of the centers. The number of centers using the sitting position was larger than in other countries like United Kingdom, Germany and Japan. Despite its lack of sensitivity capnography was universally practised. Preoperative contrast echocardiography for patent foramen ovale detection was not considered as necessary in all centers. Expert recommendations may be required.     

Tolerance of caspofungin in intensive care unit: a prospective study

Objective

Caspofungin has shown efficacy and very low toxicity in empirical antifungal therapy in refractory invasive Aspergillus infections and invasive candidiasis in neutropenic (or non) patients. To date, there is no data on tolerability of caspofungin in ICU patients. The aim of this study was to evaluate caspofungine tolerability in critical care patients.

Patients and method

Over a 36-month period, 1430 patients were admitted in a general intensive care unit. All patients data were collected in a prospective database. All the clinical or biological side effects reported in the multicentric studies were required. The patients were laminated in two groups, according to the initial hepatic function.

Results

Seventy-three patients were treated with caspofungin (5.1%) and 58% were immunocompromised. Immunosuppression was due to acute leukemia (30%), solid organ transplant (20%) or other causes of immunosuppression. In this group, SAPS2 was higher (51 ± 20 versus 44 ± 20; p < 0.05) as mortality rate was (60% versus 23%). More than 90% of patients were ventilated and 55% needed extrarenal therapy. Caspofungin treatment was initiated for aspergillosis in 12 patients, candidiasis in 33 patients and others indications. Partial or complete response to treatment was 72%. Median duration of caspofungin administration was 11 days, no liver dysfunction or acute renal failure due to caspofungin was reported whatever initial liver function was.

Conclusion

This prospective open study demonstrate the very low toxicity of caspofungin even in critical care patients.     

How colposuspensions are performed in the UK: a survey of gynecologists' practice

The authors performed a self-administered postal questionnaire survey of 690 consultant gynecologists in the UK to determine the current surgical and perioperative practice in relation to colposuspension; 350 (51%) responded. One hundred and twelve (32%) identified themselves as having a specialist interest in urogynecology. The study shows the variation in the surgical technique of colposuspension and perioperative care among gynecologists, and it provides information that may help in the development of guidelines for those involved in the surgical treatment of female urinary incontinence.Abbreviations USI Urodynamic stress incontinence - DGH District general hospital - TH Teaching hospital - TVT Tension-free vaginal tape - GSI Genuine stress incontinenceEditorial Comment: This review of practice pattern is interesting reading and should prompt other national societies to consider similar reviews. It is striking that short-term follow-up is common, with only 14% seeing patients after 6 months. This phenomenon may contribute to an overestimation of treatment response and may require more evaluation     

Half of the current practice of gastrointestinal surgery is against the evidence: a survey of the French society of digestive surgery

The French Society of Digestive Surgery conducted a survey among its members to assess whether or not the routine practice of gastrointestinal surgery is evidence based. The questionnaire included 13 questions focusing on several aspects of gastrointestinal surgery and for which strong evidence exists. The participants (n = 379) were asked to respond according to their usual practices. The response rate was 75%. Only 57% ± 15% of the responses were in accordance with the evidence. That rate of evidence-based responses did not differ according to the age of participants but was higher at university hospitals (P = 0.05).     

Acid aspiration prophylaxis in obstetrics in France: a comparative survey of 1998 vs. 1988 French practice

BACKGROUND AND OBJECTIVE: To survey French anaesthetic practice regarding acid aspiration prophylaxis and compare it with an earlier survey. METHODS: A confidential questionnaire was sent to all 800 maternity units in France to assess three major topics: (a) drugs used for pharmacological prophylaxis; (b) regional anaesthesia for labour and Caesarean section and (c) techniques used for general anaesthesia and endotracheal intubation. RESULTS: Two-hundred-and-two units responded. Pharmacological prophylaxis was regularly used for labouring women in 78% of the responding units in 1998 (compared with 63% in 1988, P < 0.05). Antacid drug use before Caesarean section had increased from 75% in 1988 to 97% in 1998 (P < 0.05). General anaesthesia was used for Caesarean section by less than 2% of responding units (vs. 21% in 1988, P < 0.05). In contrast, there was little change in the use of endotracheal intubation for instrumental delivery (53% vs. 50%) or manual removal of the placenta (15% vs. 16%) between 1988 and 1998. The use of cricoid pressure increased significantly during the 10 yr period (50% vs. 88%, P < 0.05) and the technique was correctly described by 80% of the responding units (vs. 50%, P < 0.05). Similarly, the use of succinylcholine increased significantly from 25% (1988) to 479 (1998) (P < 0.05). CONCLUSIONS: There was a significant overall improvement of French practice regarding acid aspiration prophylaxis in obstetrics. However, the complete prophylaxis strategy is still not used in every patient emphasizing the need for continuing medical education.     

French current practice for ambulatory anesthesia in children: a survey among the French-speaking Pediatric Anesthesiologists Association (ADARPEF)

Background: This survey aims to describe current practice in ambulatory care among pediatric anesthesiologists in France. Methods: Members of the French‐speaking Pediatric Anesthesiologists Association (ADARPEF) were sent a questionnaire examining the proportion of pediatric ambulatory anesthesia practiced by each responder, the level of adherence to pediatric ambulatory Anesthesia guidelines, and responder consensus in decision making when faced with common case scenarios in pediatric ambulatory anesthesia. For the latter, consensus was defined as a > 80% opinion. Results: One hundred and forty‐five pediatric anesthesiologists replied (43%). Ambulatory anesthesia appears underused in France. Recent French pediatric ambulatory anesthesia guidelines are being applied. Postoperative pain is poorly managed. The choice of scheduling children for ambulatory anesthesia appears to be more heavily influenced by practitioners’ subjective evaluation than evidence from the literature. Conclusion: A better commitment for ambulatory care must be found among anesthesiologists. Further studies are required to improve coherence, safety, and efficiency of children selection for ambulatory anesthesia.     

Pediatric anesthesia practice and training in Japan: a survey

BACKGROUND: Pediatric anesthesia in Japan is in the developing stage. The aim of this study was to review pediatric anesthesia training in Japan and to discuss the future prospects for this field. METHODS: We sent questionnaires to assess current pediatric anesthetic practice and training to all 106 university hospitals [UHs; response rate, 66% (70/106)] and all 17 children's hospitals [CHs; response rate, 87.5% (15/17)] in Japan. We also sent questionnaires to assess attitudes towards pediatric anesthetic training, to all 280 representatives of the Japanese Society of Anesthesiologists [JSA; response rate, 57.9% (162/280)]. RESULTS: The hospital survey revealed the number of pediatric anesthesia cases encountered in 15 CHs (25,009 cases) to be almost equivalent to that in 70 UHs (29,031 cases). In 19 of these UHs, there were no newborn surgical cases. Forty-nine UHs reported that no special training program existed for pediatric anesthesia, and only five UHs mandated training at CHs. Sixty-six percent of the representative JSA members considered it premature for pediatric anesthesia to become a subspecialty, but 87% considered experience in pediatric anesthesia mandatory for anesthesia board qualification. CONCLUSIONS: This survey revealed that although pediatric anesthesia training is considered mandatory, university hospitals lack adequate numbers of pediatric cases and children's hospitals suffer from a shortage of staff positions and anesthesiologists, and hence are unable to satisfy this demand. Most representative members of our society consider it too early to subspecialize pediatric anesthesia in Japan.     

Family satisfaction in intensive care unit: a prospective survey

Background

To assess family satisfaction in the intensive care unit (ICU) and to identify parameters for improvement.

Study design

Prospective observational monocentric study.

Patients and methods

One hundred and twenty families were given a questionnaire of twenty-four items covering: satisfaction with reception and waiting areas, satisfaction with care and satisfaction with information/decision-making. Each item was evaluated by families according to three levels: high, intermediate, and poor satisfaction. Opinions concerning accessibility time, information notice and visitor limitations were also gathered.

Results

Several factors, such as waiting time, respect of family's wishes, visiting hours, lack of social support, and examination's results communication were associated with poor level of satisfaction. Twenty-three percent of families felt restricted by visitation policy for children and 17 % by visitor's number limitation.

Discussion

Quality of family reception in the ICU needs to be improved concerning waiting time, visiting hours, social and emotional support.     

Attitudes to evidence-based practice in urology: results of a survey

Background : The advantages of promoting evidence‐based care through implementation of clinical guidelines are well established. Clinical practice guidelines have been developed for lower urinary tract symptoms (LUTS) and prostate cancer screening. Aspects of the delivery of care by urologists or specialist registrars relevant to the guidelines were assessed. Methods : A questionnaire was distributed at the 1999 meeting of the Urological Society of Australasia, which was attended by 187 Australasian and 33 foreign delegates. Questions addressed access to resources for evidence‐based medicine; perceived need; preferred sources of information; and then presented four clinical scenarios. These were: (i) treatment recommendations in early stage prostate cancer; (ii) the same scenario if the respondent was the patient; (iii) treatment recommendations after radical prostatectomy when there was a positive resection margin; and (iv) clinical investigations for mild to moderate LUTS. Results : Of 220 possible responses, 132 were received, a response rate of 60%. Urologists overwhelmingly (100%) endorsed the need for access to evidence‐based reviews, although 28% claimed such access was non‐existent to poor. Clinical guidelines were the preferred source of evidence‐based information. For early stage prostate cancer in a 55‐year‐old man, radical prostatectomy was recommended by 93.2% of respondents, but this dropped to 83% when the respondent was the patient (P < 0.05), and a wider range of treatments was recommended. Pelvic radiotherapy and hormone therapy were equally recommended for biochemical progression following radical prostatectomy where there was a positive surgical margin. Investigations for LUTS included serum prostate‐specific antigen (PSA) testing (78.0%) and voided flow studies (77.3%). Conclusions : Urologists express a need for evidence‐based practice resources, in particular clinical guidelines. Nevertheless their clinical approach is not necessarily consistent with existing guidelines, particularly for LUTS. An alteration in the recommendation when the respondent is the patient of interest and endorses the recommendation that patients with prostate cancer should be involved in treatment decisions.     

Post-traumatic dysautonomic crises in intensive care unit: a French national assessment

Introduction

The dysautonomic crises (DC) after traumatic brain injury are an unknown syndrome whereas the first case was described more than 50 years ago. This work aimed to collect their support modalities in French neuro-intensive cares units.

Material and methods

French medical doctors, working in neuro-intensive care unit, were questioned by mail. The questionnaire developed point of prevalence, physiopathology, diagnosis, treatment, prognostic of DC and the existence of a support protocol in the department.

Results

There were 52 replies (40%) of 25 different hospitals. The DC were common or frequent for 77% of intensivists. The large majority (94%) reported a lack of knowledge about the physiopathology of the DC. The DC presented more often a therapeutic problem (28%) than a diagnostic problem (10%). The intensivists didn’t know if the DC impacted on the prognostic of the patients (33%). The preferred treatment for the DC was an association of alpha/beta blockers and neuroleptics (38%). The more used preventive treatment was alpha/beta blockers (33%). Only two departments had a support protocol.

Conclusion

Although DC were a common complication in neuro-intensive care unit, their support seems mainly empirical.