Liver resection safety in a developing country: Analysis of a collective learning curve.

AIM OF THE STUDY: To analyze the collective learning curve in the performance of safe liver resections, using the decrease of severe postoperative complications (SPC) as a proxy for overall safety competency. MATERIAL AND METHODS: This was a retrospective analysis of a prospective database in the setting of a liver surgery program implementation in a tertiary center in Morocco. The 100 first consecutive cases of elective liver resections starting from January 1st, 2018 were included in the analysis. SPC were defined as CD>IIIa during the first 90 postoperative days. We used a cumulative sum (CUSUM) technique to determine the number of cases required to achieve safety competency. We then compared case characteristics before and after the learning curve completion. RESULTS: SPC occurred in 15 cases (15%), including 5 deaths (5%). The CUSUM chart revealed a learning curve completion at the 49th case, marked by an inflection point towards the decrease in SPC (24.5% vs 5.9%; P=0.009). In period 2 (after), cases were associated with less diabetes, less synchronous digestive resection, more cirrhosis, and more prolonged preoperative chemotherapy. The rates of major resection (30.6% vs 29.9%; P=0.89) and biliary reconstruction were comparable, as were the operating time, and estimated blood loss. CONCLUSION: Approximately 50 cases were required to complete the learning curve and improve the overall safety of liver resection. In our setting, the learning curve chronology was consistent with collective measures, including team stabilization and protocol development.

Evaluation and management of thromboprophylaxis in Moroccan hospitals at national level: the Avail-MoNa study.

Venous thromboembolism (VTE) is a common clinical problem that is associated with substantial morbidity and mortality. The aim of this study was to describe the clinical practices in VTE prophylaxis in university and peripheral hospitals in Morocco. This is a national, cross-sectional, multicenter, observational study assessing the management of the VTE risk in selected Moroccan hospitals (four university and three peripheral). The thromboembolic risk of the selected patients was assessed according to the American College of Chest Physicians (ACCP) guidelines (2008). We hypothesized that interventions for VTE guideline implementation in those hospitals may improve prophylaxis use for hospitalized patients. A total of 1318 patients were analyzed: 467 (35.5%) medical and 851 (64.5%) surgical. The mean age of patients was 52.6 ± 16.5 years, and 52.7% were female. A total of 51.1% patients were considered to be at risk of VTE according to ACCP guidelines and were eligible for thromboprophylaxis (TP). Medical patients were more likely to present risk factors than surgical patients (53.6 vs. 50.7%, respectively). TP was prescribed for 53.1% of these patients, 57.4% in at-risk surgical patients and 50.3% in at-risk medical patients. TP was also prescribed for 42.9% of non-at-risk patients. The concordance between the recommended and the prescribed prophylaxis was poor for the total population (kappa = 0.110). TP did not improve sufficiently in our hospitals, even after implementation of the guidelines. New strategies are required to appropriately address TP in hospitalized patients.

[Medication errors in anesthesia: a Moroccan university hospitals survey]. / Erreurs médicamenteuses en anesthésie : enquête prospective au niveau des CHU Marocains.

INTRODUCTION: Medication errors are a major public health problem because of their morbidity and financial costs. In anesthesia, few articles publications, mostly retrospective, have assessed its incidence and outcomes. By our prospective study, we intend to identify and describe the drug errors in anesthesia in four university hospitals in Morocco. MATERIAL AND METHODS: After approval of our ethics committee, a prospective study was conducted in nine hospitals affiliated to four university hospitals (Rabat, Casablanca, Fes and Marrakech) from October 2009 to June 2010. Data collection was carried out by an anesthesiologist at each hospital who was designated by the investigator. Informations were based on practitioner's statements. Medication errors were divided into distinct categories: substitution errors, omission errors, errors of the way of administration, dosage and dilution errors. The consequences were classified into four levels according to their severity. RESULTS: During the study period, 9199 anesthetic procedures were reported (mean response of 36%). General anesthesia was performed in 75% of patients. Sixteen cases of drug errors were reported (an incidence of 1/575 with 1/405 in a pediatric setting). The drugs involved were dominated by hypnotics (six cases/16) and morphine (four cases/16). Medication errors were mainly due to labeling mistakes (seven cases/16) and to attention deficit due to fatigue and stress (seven other cases) leading to substitution error in most of cases (10 cases/16. Errors were mainly made by the less experienced practitioners (14 cases/16). They occurred during the induction phase (seven cases/16) as well as during the interview process (nine cases/16), and also during emergent surgeries (seven errors/16) as well as during elective ones (nine errors/16). No errors caused death. Pulmonary edema (recognized as a grade III severity incident) was secondary to inappropriate administration of adrenaline. CONCLUSION: Our study helped us to set recommendations, which are approved by the Moroccan pharmacovigilance center, and in accordance with the international committees to prevent the occurrence of medication errors in our daily anesthetic practice.

[Internal jugular venous cannulation: what is the best approach?]. / Cathétérisme veineux jugulaire interne : quelle est la meilleure voie d'abord ?

OBJECTIVES: The aim of this study was to compare two approaches used for internal jugular venous cannulation: the anterior way, described by English et al. and the posterior way, described by Jernigan et al. The primary endpoint was the rate of success. The secondary endpoints were the related adverse events and the difficulty factors. STUDY DESIGN: Prospective, randomized open clinical trial. PATIENTS AND METHODS: The study took place in the vital emergency room, the operating room and the emergency intensive care unit of Ibn Sina University hospital (Rabat, Morocco), between June and September 2010. Hundred and one patients needing a central venous catheter were randomized to undergo one of the two techniques. We compared: demographics, success rates, number of attempts, difficulty factors and adverse events. RESULTS: The success rate was significantly higher in the posterior group (96% versus 68%, P < 0.001), with fewer attempts (1.3 ± 0.7 versus 2.1 ± 1.3; P < 0.001). There were less pneumothorax, (0 versus 6%) and more accidental arterial punctures (34 versus 25.5%) in the posterior group, but the difference wasn't significant. Finally, none of the difficulty factors were correlated to the failure rate. CONCLUSION: This study shows that the posterior approach in internal jugular venous cannulation is more efficient than and as safe as the anterior approach.

[Traumatic asphyxia or Perthe's syndrome. Six cas reports]. / Syndrome d'asphyxie traumatique ou syndrome de Perthes. A propos de six cas.

Perthe's syndrome or traumatic asphyxia is a clinical syndrome associating cervicofacial cyanosis, petechia and subconjonctival hemorrhage to neurological symptoms. This syndrome appears after severe and transient compressive blunt chest injury. A Valsalva maneuver is necessary before thoracic compression for the development of this syndrome. The treatment includes rapid chest decompression and cardiopulmonary resuscitation. The prognosis is good but a prolonged thoracic compression could lead to cerebral anoxia and neurological sequelae. We report six cases of Perthe's syndrome most of them resulting from thoracic compression after road traffic accidents. All of them made a good prognosis.