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ABSTRACT: 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 The urinary catheter was withdrawn after h24 in 71% of responding centres.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 24hours (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.
Annales francaises d'anesthesie et de reanimation 02/2013; · 0.77 Impact Factor
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Annales francaises d'anesthesie et de reanimation 01/2013; · 0.77 Impact Factor
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Annales francaises d'anesthesie et de reanimation 11/2012; · 0.77 Impact Factor
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ABSTRACT: The authors report three cases in which cerebral ischemia occurred during arthroscopic shoulder surgery performed in beach chair position under general anaesthesia and interscalene plexus block. Several similar cases have been published in the literature. This rare but extremely severe complication is related to the decrease in cerebral perfusion pressure (CPP). Monitoring of CPP in the beach chair position using the measurement of arterial pressure and taking into account the hydrostatic gradient is essential. Prevention includes correction of preoperative hypovolaemia, treatment of postural arterial hypotension, adequate installation of the patient's head, aggressive treatment of perioperative arterial hypotension (whatever the cause) and avoidance of deliberate perioperative arterial hypotension. Routine use of non-invasive monitoring of cerebral oxygenation has been advocated to avoid this accident but its usefulness has to be confirmed by clinical studies.
Annales francaises d'anesthesie et de reanimation 10/2012; · 0.77 Impact Factor
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ABSTRACT: OBJECTIVE:: To determine the predictive value of the renal resistive index (RI) and cystatin C values in serum (SCys) and urine (UCys) in the development of acute kidney injury (AKI) in critically ill patients with severe sepsis or polytrauma. DESIGN AND SETTING:: prospective, double-centre, descriptive study. PATIENTS AND PARTICIPANTS:: 58 patients with severe sepsis (n = 28) or polytrauma (n = 30). MEASUREMENTS AND RESULTS:: RI, SCys and UCys were measured within the 12 hours following admission (Day 1, D1) to the intensive care unit (ICU). Renal function was assessed using the AKI network classification: On day 3 (D3), 40 patients were stage 0 or 1, and 18 were stage 2 or 3. Patients with AKI stage 2 or 3 had significantly higher RI (0.80 vs. 0.66, p < 0.0001), SCys (1.23 vs. 0.68 mg/L, p = 0.0002) and UCys (3.32 vs. 0.09 mg/L, p = 0.0008). They also had higher SAPS II, arterial lactate and ICU mortality. In multivariate analysis, a RI > 0.707 on D1 was the only parameter predictive of the development of AKI stage 2 or 3 on D3 (p=0.0004). In the subgroup of patients with AKI stage 2 or 3 on D1, RI remained the only parameter associated with persistent AKI on D3 (p=0.016). CONCLUSION:: In multivariate analysis comparing the predictive value of RI, SCys and UCys, RI was the only parameter predictive of AKI stage 2 or 3 on D3. RI seems to be a promising tool to assess the risk of AKI.
Shock (Augusta, Ga.) 10/2012; · 2.87 Impact Factor
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ABSTRACT: Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008-2009 by a second wave concerning 42 active drugs.
The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals.
The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians.
This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors.
Annales francaises d'anesthesie et de reanimation 12/2011; 31(1):15-22. · 0.77 Impact Factor
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ABSTRACT: A 34-year-old multiparous woman with a breech presentation, intrauterine growth restriction and premature rupture of membranes was transferred to our referral unit at 33 weeks of gestation. She was diagnosed with Alagille syndrome soon after birth because of cholestasis and pruritus. Her condition was later complicated by esophageal varices, treated with propranolol, thrombocytopenia, and insulin-dependent diabetes. She had characteristic facies, posterior embryotoxon, "butterfly" vertebrae but had no cardiac or renal abnormalities. Due to the early onset of spontaneous labor, emergency cesarean section under general anesthesia was performed 48 h after admission. This is the first case describing anesthetic care during delivery in a patient with Alagille syndrome. We discuss the anesthetic implications of the syndrome, emphasizing problems associated with portal hypertension and cholestasis, thrombocytopenia and cardiac abnormalities such as pulmonary artery stenosis.
International journal of obstetric anesthesia 09/2011; 20(4):355-8. · 1.85 Impact Factor
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ABSTRACT: Post-dural puncture headache (PDPH) might be related to cerebrospinal fluid hypotension. Studies in brain-injured patients have shown a good relationship between optic nerve sheath diameter (ONSD) measured by ocular sonography and invasively measured intracranial pressure (ICP). The aim of this study was to evaluate changes in ONSD after lumbar epidural blood patch (EBP).
Consecutive subjects receiving an EBP for PDPH were included. ONSD and pain measurements were performed before (T(0)), 10 min (M(10)), 2 h (H(2)), and 20 h (H(20)) after the EBP.
Ten subjects were included. ONSD [median (inter-quartile range)] increased with time after EBP, from 4.8 mm (4.5-5.1) at T(0) to 5.2 mm (4.9-5.7) at M(10) (P=0.005 vs T(0)), 5.5 mm (5.1-6.0) at H(2) (P=0.007 vs T(0)), and 5.8 mm (5.2-6.3) at H(20) (P=0.02 vs T(0)). EBP was clinically successful in nine of 10 subjects. In subjects in whom EBP was successful, ONSD significantly increased at M(10) and T(2) compared with T(0) (P=0.004 and 0.008, respectively) but did not reach statistical significance at H(20) (P=0.06). In the subject in whom EBP failed, a small increase in ONSD was observed over time.
In this preliminary report, EBP was followed by ONSD enlargement in subjects with successful EBP, but not in the subject with EBP failure. Since ONSD is a surrogate marker of ICP, this suggests that a sustained increase in ICP is associated with successful EBP.
BJA British Journal of Anaesthesia 06/2011; 107(4):627-30. · 4.24 Impact Factor
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ABSTRACT: Cytokines are secreted locally in response to surgery and may be released into the systemic circulation. Reactive oxygen species (ROS) production is involved in various inflammatory conditions. The aims of the study were to examine the magnitude of surgical stress on the modulation of immune response and ROS production.
Patients undergoing low- and intermediate-risk surgery (n=32) were enrolled. Blood samples for tumor necrosis factor (TNF)α, interleukin (IL)1β and IL10 assays were obtained before anesthesia, immediately after extubation, at 24 and 72 h after surgery. Measurement in whole-blood cultures of ex vivo lipopolysaccharide (LPS) and Staphylococcus aureus Cowan (SAC)-stimulated production of cytokines was carried out. The pro-oxidant potency of the whole serum was assessed in human umbilical vein endothelial cells using a fluorescent probe after stimulation by the plasma collected at the same time intervals.
TNFα, IL1β and IL10 did not increase significantly after surgery in either group. Whole-blood cultures response to LPS and SAC stimulation decreased for IL1β at the end of surgery in the two groups and returned to normal within 24 h after surgery. LPS- and SAC-induced IL10 production increased significantly at 24 h in the low-risk surgery group. ROS production was greater after more stressful surgery and was correlated to morphine consumption.
Cytokine release in the systemic circulation was not well correlated to the magnitude of surgical stress, whereas transient immune hyporesponsiveness was seen after moderately stressful surgery. ROS production might be a more accurate indicator of the severity of surgical trauma.
Acta Anaesthesiologica Scandinavica 03/2011; 55(5):549-57. · 2.19 Impact Factor
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Annales francaises d'anesthesie et de reanimation 02/2011; 30(4):329-30. · 0.77 Impact Factor
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ABSTRACT: We describe the case of two patients who had undergone gynecologic surgery and in whom a continuous ropivacaine infusion was administered through a catheter placed on each abdominal side, using the technique of ultrasound-guided TAP block. Postoperative analgesia was of excellent quality with almost no morphine requirement. No side effects were encountered.
Annales francaises d'anesthesie et de reanimation 01/2011; 30(1):67-9. · 0.77 Impact Factor
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ABSTRACT: to compare the number and the cost of preoperative tests ordered before scheduled surgery before and after implementation of local guidelines.
observational retrospective survey.
All patients scheduled in seven surgical specialties.
all preoperative tests ordered during a 1-week period (2008) were noted. Local guidelines based on published guidelines and validated by anesthesiologists of the hospital were then implemented. A second audit was performed 1 year after (2009).
Eighty-five and 79 patients' files were analyzed in 2008 and 2009, respectively. On average, half (46% in 2008 and 58% in 2009) of prescriptions did not follow the guidelines, with anaesthesiologists prescribing more than their own recommendations. Overall conformity to the local guidelines did not improve between 2008 and 2009. However, EKG (79% vs. 95%, p<0.05) and serum electrolytes (72% vs. 99%, p<0.05) ordered were significantly in better agreement with the guidelines. Costs associated with inadequate orders were divided by 2.4 in 2009.
existing practice is overall poor. Non-compliance of preoperative testing to guidelines is a significant cause of uncontrolled cost. Change in compliance is a slow process.
Annales francaises d'anesthesie et de reanimation 12/2010; 29(12):868-73. · 0.77 Impact Factor
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Annales francaises d'anesthesie et de reanimation 11/2010; 29(11):826. · 0.77 Impact Factor
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International journal of obstetric anesthesia 10/2010; 20(1):97-8. · 1.85 Impact Factor
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ABSTRACT: We report the case of a patient in whom three blood patches had to be performed to treat a post-dural puncture headache following the insertion of an epidural catheter for labour analgesia. There are few data about repeated blood patches used to treat recurring symptoms after failure of a previous blood patch. The technical guidelines used to perform a first blood patch should be followed for the next procedure as well. The role of the cerebrospinal fluid leaking in the symptoms has to be verified, to avoid performing a useless blood patch and to miss another cause, which needs an urgent treatment.
Annales francaises d'anesthesie et de reanimation 10/2010; 29(11):803-6. · 0.77 Impact Factor
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Annales francaises d'anesthesie et de reanimation 10/2009; 28(10):833-5. · 0.77 Impact Factor
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ABSTRACT: Death certificates from the French national mortality database for the calendar year 1999 were reviewed to analyse cases in which airway complications had contributed to peri-operative death. Respiratory deaths (and comas) found in a previous national 1978-82 French survey (1:7960; 95% CI 1:12,700 to 1:5400) were compared with the death rate found in the present one: 1:48,200 (95% CI 1:140,000 to 1:27,500). In 1999, deaths associated with failure of the breathing circuit and equipment were no longer encountered and no death was found to be related to undetected hypoxia in the recovery unit. Deaths related to difficult intubation also occurred at a lower rate than in the previous report (1:46,000; 95% CI 1:386,000 to 1:13,000) in 1978-82 vs 1:176,000 (95% CI 1:714,000 to 1:46,000) in 1999, a fourfold reduction. In most cases, there were both inadequate practice and systems failure (inappropriate communication between staff, inadequate supervision, poor organisation). This large French survey shows that deaths associated with respiratory complications during anaesthesia have been strikingly reduced during this 15-year period.
Anaesthesia 05/2009; 64(4):366-70. · 2.96 Impact Factor
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Annales francaises d'anesthesie et de reanimation 05/2009; 28(5):431-3. · 0.77 Impact Factor
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ABSTRACT: Aspiration of gastric contents is a major complication in relation with the practice of anaesthesia. The present article is aimed at describing detailed data related to aspiration which were obtained during the French national survey on anaesthesia-related mortality conducted by both Sfar and CépiDC-Inserm. Information regarding methods of the survey and the main results has been previously published. In brief, the first part of the survey described the number and characteristics of anaesthetic procedures performed in 1996 (denominator). The second survey analysed deaths related to anaesthesia which were identified from death certificates of the calendar year 1999. Because of the numerical importance of aspiration among the causes of deaths, a secondary analysis was undertaken to assess into details factors leading to the occurrence of this complication. Eighty-three cases of death were found related to aspiration, i.e. one-fifth of deaths related completely or partially to anaesthesia, implying a death rate of one for 221,368 general anaesthetic procedures or 4.5 x 10(-6) (95% IC: 0.8 x 10(-6)-14 x 10(-6)). Patients involved were all in a severe clinical condition (ASA> or =3: 92%), very old and often scheduled for urgent abdominal surgery. Two cases of death occurred during colonoscopy but none in obstetric patients. Aspiration almost always occurred during induction of anaesthesia. Analysis of practice patterns disclosed significant deviations from recommendations. French anaesthetists should voluntarily move through a personal and active process toward an improvement of their practice to reduce the incidence of aspiration.
Annales francaises d'anesthesie et de reanimation 03/2009; 28(3):200-5. · 0.77 Impact Factor
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Annales francaises d'anesthesie et de reanimation 02/2009; 28(2):115-8. · 0.77 Impact Factor
