Extensive suppuration and being overweight are factors associated with the failure of laser treatment for pilonidal disease: lessons from the first French retrospective cohort

Techniques in Coloproctology - The aim of our study was to assess the efficacy of sinus laser therapy (SiLaT) for the treatment of pilonidal disease. All adult patients treated with SiLaT in our...     

Accounting for failure: risk-based regulation and the problems of ensuring healthcare quality in the NHS

In this paper, we examine why risk-based policy instruments have failed to improve the proportionality, effectiveness, and legitimacy of healthcare quality regulation in the National Health Service (NHS) in England. Rather than trying to prevent all possible harms, risk-based approaches promise to rationalise and manage the inevitable limits of what regulation can hope to achieve by focusing regulatory standard-setting and enforcement activity on the highest priority risks, as determined through formal assessments of their probability and consequences. As such, risk-based approaches have been enthusiastically adopted by healthcare quality regulators over the last decade. However, by drawing on historical policy analysis and in-depth interviews with 15 high-level UK informants in 2013–2015, we identify a series of practical problems in using risk-based policy instruments for defining, assessing, and ensuring compliance with healthcare quality standards. Based on our analysis, we go on to consider why, despite a succession of failures, healthcare regulators remain committed to developing and using risk-based approaches. We conclude by identifying several preconditions for successful risk-based regulation: goals must be clear and trade-offs between them amenable to agreement; regulators must be able to reliably assess the probability and consequences of adverse outcomes; regulators must have a range of enforcement tools that can be deployed in proportion to risk; and there must be political tolerance for adverse outcomes.     

Desflurane improves the throughput of patients in the PACU. A cost-effectiveness comparison with isoflurane

PURPOSE: In a pharmacoeconomic approach of anesthesia, postanesthesia care unit (PACU) occupancy can be chosen as a criteria of effectiveness to compare two anesthetic drugs with different rates of elimination and different costs of administration. Our objective was to develop a cost-effectiveness approach for the comparison of isoflurane (I) and desflurane (D). METHOD: In this prospective observational study, 68 patients aged 18-70 received either D or I for maintenance of anesthesia for inpatient abdominal procedures. Length of stay (LOS) in PACU was collected by a blinded observer. After the relationship between duration of surgery and LOS in PACU had been established in the 68 observed patients, we estimated the PACU occupancy according to duration of surgery and time of admission in PACU using a computer model of 204 consecutive patients, based on the hypothesis of an exclusive use of either D or I. Outcome measures were direct costs of the anesthesia procedure and occupancy of the PACU. RESULTS: The direct cost of the anesthetic was significantly higher with D than with I. This represents an increase of CAN$ 2 708 for the 204 patients. PACU occupancy was reduced by at least one patient (out of five beds) during 26.1% of the time with D (P <0.01). DISCUSSION: Improving the throughput of patients in PACU by using new halogenated anesthetic agents with faster rates of elimination may outweigh the incremental cost of this strategy. This becomes particularly meaningful in operating theatres experiencing frequent overcrowded periods.     

Haemodynamic stability during moderate hypotensive anaesthesia for spinal surgery. A comparison between desflurane and isoflurane

BACKGROUND: The aim of this study was to compare desflurane and isoflurane for spinal procedures requiring moderate levels of controlled arterial hypotension, when these agents were administered via a semi-closed circuit at 1 l x min(-1) fresh gas flow. METHODS: After ethics committee approval and written informed consent, 20 ASA I or II patients were randomly allocated to receive either desflurane (n=10) or isoflurane (n=10), in O2/ N2O (1:1) for maintenance of anaesthesia. Induction of anaesthesia, fentanyl dosing and volume loading were standardized. Blood pressure was invasively monitored and maintained within a target systolic blood pressure (SBP) range of 80 to 100 mmHg during the study period. Results were presented as medians and interquartiles, and non-parametric statistical methods were used. RESULTS: Patient demographic data, SBP and heart rate prior to surgery, and duration of the procedure were similar between the two groups. During the study period, tighter arterial blood pressure control was maintained with desflurane as compared with isoflurane. SBP was 21.2% (9.5-41.7) of time outside the range 80-100 mmHg with isoflurane and 5.1% (0.6-10.3) with desflurane (P<0.01). CONCLUSIONS: Desflurane, administered via a semi-closed circuit at 1 l x min(-1) fresh gas flow, maintained better haemodynamic stability in spinal surgery requiring moderate arterial hypotension than isoflurane.     

An observational evaluation of the rate of awakening after isoflurane or desflurane used in daily clinical practice

Study objective: To evaluate the rate of awakening after desflurane (D) or isoflurane (I) anesthesia when used during daily clinical practice.

Design: Observational prospective study.

Setting: University-affiliated metropolitan hospital.

Patients: 68 ASA physical status I and II patients (18–75 yrs) scheduled for abdominal surgeries.

Interventions: Patients scheduled for abdominal surgery of various duration received either D or I. No time was specified for discontinuation of the inhaled drugs at the end of the surgery. T₀ for recovery parameters was stated as the end of the surgery. A p-value < 0.05 was considered as significant. Results are expressed as medians and ranges.

Measurements and Main Results: 68 patients (32 in D group and 36 in I group) were analyzed. Patient demographic data were similar between the two groups. Duration of surgery was 151 minutes (83–428 min) and 174 minutes (40–552 min) for I and D, respectively. Extubation occurred earlier after D (18 min [9–35 min]) as compared to I (32 min [7–77 min]). Time to reach the Aldrete score at 10 was faster after D (30 min [12–45]) as compared to I (46 min [15–110]). Unlike I, the rate of awakening after D was independent of the duration of surgery. The differences between D and I reached statistical significance in surgical procedures lasting more than 100 minutes.

Conclusion: Used during routine conditions, D allows for faster recovery than I in surgical procedures lasting more than 100 minutes. The rate of awakening after D remained independent of the duration of the surgical procedure.     

Inguinal herniorrhaphy under monitored anesthesia care with ilioinguinal-iliohypogastric block: the impact of adding clonidine to ropivacaine

There is no information concerning the association of ropivacaine and clonidine for ilioinguinal-iliohypogastric block. In this prospective, double-blind study, we randomly assigned 40 adult patients scheduled for inguinal herniorrhaphy under monitored anesthesia care to receive either 225 mg ropivacaine (7.5 mg/mL) alone (control group) or combined with 75 mug clonidine (clonidine group) for preoperative ilioinguinal-iliohypogastric block. After completion of surgery, patients were transferred to the postanesthesia care unit and were asked to stand up and walk around at the second postoperative hour. After leaving the postanesthesia care unit, patients could take oral propacetamol (500 mg) and codeine (30 mg) on request. Pain intensity was assessed with a 100 mm visual analog scale. Time to first request of supplemental analgesics (median [95% confidence interval]) was 10 h (7.1-14.5 h) and 9 h (6.4->24 h) respectively in the clonidine and control groups (P = 0.83). Pain at rest did not differ between groups whereas pain at motion was reduced on the third postoperative day in the clonidine group. More patients who received clonidine experienced orthostatic hypotension upon standing up within the first postoperative hours (6 of 20 versus 1 of 20 in the control group; P < 0.05). In conclusion, the benefit of adding clonidine 75 mug to ropivacaine for ilioinguinal-iliohypogastric block for motion pain on the third postoperative day must be balanced with an increasing risk of orthostatic hypotension in the immediate postoperative period.     

Pre-peritoneal continuous infusion of local anesthetics for pain relief after laparotomy. A preliminary report

INTRODUCTION: Continuous administration of local anesthetic through a catheter placed in the scar of a laparotomy is a postoperative analgesic technique, which seems effective but remains little developed and poorly codified. METHODS: In this prospective evaluation, we present a series of 25 observations of adult patients scheduled for abdominal laparotomy, to which a multiperforate catheter was placed at the end of the intervention by the surgeon in pre-peritoneal position, allowing the continuous perfusion of ropivaca?ne over the first 48 postoperative hours. Patients received intravenous paracetamol associated with ketoprophene or nefopam. Opiates were given as rescue analgesics, in case of failure in pain relief, defined on objective criteria measured on visual analogic scale (VAS). RESULTS: The feasibility of the technique was excellent, except in one case of catheter obstruction. Pain was adequately relieved, with a majority of patients having VAS scores lower than 3/10 cm with the VAS, as well as rest as during mobilization. Only 9 patients needed morphine rescue analgesics. There was no sign of clinical overdose nor parietal complication related to the technique. Blood dosages of ropivacaine, carried out among 5 patients having received 600 mg daily, showed serum concentrations below the thresholds of toxicity. CONCLUSIONS: These results reveal a good effectiveness of the method, with moderate pain intensity and a low analgesic consumption. The local and general tolerance was excellent.     

Clinical Interest and Economic Impact of Preoperative SMS Reminders before Ambulatory Surgery: A Propensity Score Analysis

Patient contact by telephone the day before ambulatory surgery is considered as a best practice. The Short Message Service (SMS) could be a suitable alternative. The objective of this prospective study was to evaluate the interest of preoperative instruction (PI) reminders by SMS compared to telephone calls. This was a prospective single center before-and-after study. Patients scheduled in ambulatory surgery were included during 2 consecutive periods of 10 weeks. The “Call” group received a telephone call for preoperative instructions (PI) and the “SMS” group received an automated protocol SMS reminder. The primary endpoint was patient compliance with PI and time of convocation. The two populations were compared with a non-inferiority hypothesis and the impact of the contact modality on compliance with the PI was assessed using a propensity score. The analysis concerned 301 patients in the Call group and 298 in the SMS group. The absence of dysfunction was observed in 75% of patients in the SMS group compared with 61% in the Call group (Risk difference: 14% [95%CI: 7–21]). The use of SMS was associated with a significant improvement in compliance with the PI (Odds ratio: 1.90 [1.48–2.42]; p?<?0.0001). Patient satisfaction was similar regardless of the method of PI reminders. The automation of preoperative SMS reminders is associated with a better respect of the PI compared to the conventional calling method. This PI reminder method satisfies the majority of patients and may have a favorable financial impact.