[Perioperative conflicts between anaesthesiologists and surgeons: ethics and professionalism]. / Conflits en période périopératoire: un enjeu collectif, éthique et professionnel.

In the perioperative period, several potential conflicts between anaesthetists/intensive care specialists and surgeons may exist. They are detrimental to the quality of patient care and to the well-being of the teams. They are a source of medical errors and contribute to burn-out. Patients can become the victims of such conflicts, which deserve ethical reflection. Their resolution through analysis and shared solutions is necessary. This article seeks to analyse these conflicts, taking into account their specificities and constraints. In order to understand this context, it is important to consider the specificities of each group involved and the records of such situations. Several factors can prevent these conflicts, first and foremost the patients themselves and the quality of the care that is provided. Medical deontology aims mainly at preventing and resolving these conflicts. Generally speaking, the quality approach which is increasingly applied in health care institutions (involving declarations of adverse events, morbidity/mortality reviews, benchmarking, analysis and improvement of practices, etc.) also contributes to the prevention and resolution of disagreements. The teaching of communication techniques that begins with the initial training, the evaluation of team behaviours (through simulation training for example), the respect of others' constraints, particularly when it comes to learning, as well as transparency regarding conflicts of interests, are all additional elements of conflict prevention. Lastly, conflicts may at times be caused by deviant behaviours, which must be met with a clear and uncompromising collective and institutional approach. This article concludes by offering a standardised approach for conflict resolution.

Increasing mean arterial pressure during cardiac surgery does not reduce the rate of postoperative acute kidney injury.

INTRODUCTION: We hypothesized that the optimization of renal haemodynamics by maintaining a high level of mean arterial blood pressure (MAP) during cardiopulmonary bypass (CPB) could reduce the rate of acute kidney injury (AKI) in high-risk patients. METHODS: In this randomized, controlled study, we enrolled 300 patients scheduled for elective cardiac surgery under cardiopulmonary bypass. All had known risk factors of AKI: serum creatinine clearance between 30 and 60 ml/min for 1.73 m(2) or two factors among the following: age >60 years, diabetes mellitus, diffuse atherosclerosis. After a standardized fluid loading, the MAP was maintained between 75-85 mmHg during CPB with norepinephrine (High Pressure, n=147) versus 50-60 mmHg in the Control (n=145). AKI was defined by a 30% increased of serum creatinine (sCr). We further tested others definitions for AKI: RIFLE classification, 50% rise of sCr and the need for haemodialysis. RESULTS: The pressure endpoints were achieved in both the High Pressure (79 ± 6 mmHg) and the Control groups (60 ± 6 mmHg; p<0.001). The rate of AKI did not differ by group (17% vs. 17%; p=1), whatever the criteria used for AKI. The length of stay in hospital (9.5 days [7.9-11.2] vs. 8.2 [7.1-9.4]) and the rate of death at day 28 (2.1% vs. 3.4%) and at six months (3.4% vs. 4.8%) did not differ between the groups. CONCLUSION: Maintaining a high level of MAP (on average) during normothermic CPB does not reduce the risk of postoperative AKI. It does not alter the length of hospital stay or the mortality rate.

Critical appraisal of organ procurement under Maastricht 3 condition.

The ethics committee of the French Society of Anesthesia and Intensive Care (Sfar) has been requested by the French Biomedical Agency to consider the issue of organ donation in patients after the decision to withdraw life-supportive therapies has been taken. This type of organ donation is performed in the USA, Canada, the United Kingdom, the Netherlands and Belgium. The three former countries have published recommendations formalizing procedures and operations. The French Society of Anesthesia and Intensive Care (Société française d'anesthésie et de reanimation [Sfar]) ethics committee has considered this issue and envisioned the different aspects of the whole process. Consequently, it sounded a note of caution regarding the applicability of this type of organ procurement in unselected patients following a decision to withdraw life-supportive therapies. According to French regulations concerning organ procurement in brain-dead patients, the committee stresses the need to restrict this specific way of procurement to severely brain-injured patients, once confirmatory investigations predicting a catastrophic prognosis have been performed. This suggests that the nature of the confirmatory investigation required should be formalized by the French Biomedical Agency on behalf of the French parliamentarians, which should help preserve population trust regarding organ procurement and provide a framework for medical decision. This text has been endorsed by the Sfar.

[Euthanasia, assisted suicide and palliative care: a review by the Ethics Committee of the French Society of Anaesthesia and Intensive Care]. / Fin de vie, euthanasie et suicide assisté : une mise au point de la Société française d'anesthésie et de réanimation (Sfar).

CONTEXT: Management of the end of life is a major social issue which was addressed in France by law, on April 22nd 2005. Nevertheless, a debate has emerged within French society about the legalization of euthanasia and/or assisted suicide (E/AS). This issue raises questions for doctors and most especially for anesthetists and intensive care physicians. OBJECTIVE: To highlight, dispassionately and without dogmatism, key points taken from the published literature and the experience of countries which have legislated for E/AS. RESULTS: The current French law addresses most of the end of life issues an intensive care physician might encounter. It is credited for imposing palliative care when therapies have become senseless and are withdrawn. However, this requirement for palliative care is generally applied too late in the course of a fatal illness. There is a great need for more education and stronger incentives for early action in this area. On the rare occasions when E/AS is requested, either by the patient or their loved-ones, it often results from a failure to consider that treatments have become senseless and conflict with patient's best interest. The implementation of E/AS cannot be reduced to a simple affirmation of the Principle of autonomy. Such procedures present genuine difficulties and the risk of drift. CONCLUSION: We deliver a message of prudence and caution. Should we address painful end of life and moral suffering issues, by suppressing the subject, i.e. ending the patient's life, when comprehensive palliative care has not first been fully granted to all patients in need of it ?

[Critical appraisal of organ procurement under Maastricht 3 condition]. / Analyse critique du prélèvement en condition M3 de Maastricht.

The ethics committee of the French Society of Anesthesia and Intensive Care (Sfar) has been requested by the French Biomedical Agency to consider the issue of organ donation in patients after a decision of withdrawing life supporting therapies has been taken. This category of organ donation is performed in the USA, Canada, United Kingdom, the Netherlands and Belgium. The three former countries have published recommendations, which formalize procedures and operations. The Sfar ethics committee has considered this issue and envisioned the different aspects of the whole process. Consequently, it sounds a note of caution regarding the applicability of this type of organ procurement in unselected patient following a decision to withdraw life supporting therapies. According to the French regulation concerning organ procurement in brain dead patients, the committee stresses the need to restrict this specific way of procurement to severely brain injured patients, once confirmatory investigations predicting a catastrophic prognosis have been performed. It suggests that the nature of the confirmatory investigation required should be formalized by the French Biomedical Agency on behalf of the French parliamentarians. This should help preserving population trust regarding organ procurement and provide a framework to medical decision. This text has been endorsed by the Sfar.

[Circumcision in children: an organizational or an ethical challenge?]. / Circoncision chez l'enfant : une simple question d'organisation des soins ou un enjeu éthique ?

OBJECTIVES: To review society, ethical and anaesthesiological issues related to circumcision in children. STUDY DESIGN: Review. METHODS: Pubmed search and expert opinion RESULTS: Circumcision concerns 30 of male world population. Reasons are ritual, medical and hygienic. In Muslims, circumcision is usual performed before the age of six. Surgery is performed at best under sevoflurane general anaesthesia and a penile bloc. Level 1 and level 2 antalgics are used for 72 hours, once the bloc has elapsed. In Jews, circumcision is performed soon after birth, in the community. Emla is the most convenient antalgics in this case. Except in case of emergency, circumcision under general anaesthesia should be delayed after 3 months as general anaesthesia is suspect to exert cerebral toxicity. Before the age of one year, there is a risk of increased respiratory problems following general anesthesia. Therefore, circumcision under general anaesthesia should be performed after one year of age. Circumcision may represent an adjunct to limit AIDS transmission in endemic countries. CONCLUSION: The ethical point associated with circumcision is to allow best analgesia, in a way matching child's age. Analgesia, is achievable by both the surgeon and the anesthesiologist.

Early detection of postoperative acute kidney injury by Doppler renal resistive index in cardiac surgery with cardiopulmonary bypass.

BACKGROUND: Acute kidney injury (AKI) is common after cardiac surgery, affecting outcome. Early detection of an AKI marker is likely to speed diagnosis and implementation of measures to preserve renal function. In septic shock and unselected ventilated subjects, an increased Doppler renal resistive index (RRI) is a predictor of AKI. This study aims to determine whether RRI would act similarly in the postoperative setting of cardiac surgery. METHODS: This study included 65 subjects aged more than 60 yr undergoing elective heart surgery with cardiopulmonary bypass (CPB) and at risk of AKI. All presented at least one AKI risk factor [arteritis, diabetes, or serum creatinine (sCr) clearance of 30-60 ml min(-1)] and were haemodynamically stable without arrhythmia. Doppler RRI was measured in the immediate postoperative period (POP) while subjects were ventilated and sedated. AKI was assessed when sCr increased 30% above the preoperative baseline. RESULTS: Eighteen subjects developed AKI between days 1 and 4, with six requiring dialysis. RRI in the POP was increased in AKI [RRI: 0.79 (0.08) with AKI vs 0.68 (0.06) without AKI, P<0.001], correlating to AKI severity [0.68 (0.06) without AKI, 0.77 (0.08) with AKI but no dialysis, and 0.84 (0.03) with AKI and dialysis, P<0.001]. RRI was similar in subjects receiving catecholamines. RRI >0.74 in the POP predicted delayed AKI with high sensitivity and specificity (0.85 and 0.94, respectively). Multivariate analysis showed that AKI was associated with increased RRI and transfusion. CONCLUSIONS: RRI used in the immediate POP after cardiac surgery with CPB enabled prediction of delayed AKI and anticipation of its severity.

[Endotracheal tube cuff and nitrous oxide: bench evaluation and assessment of clinical practice]. / Sondes d'intubation et protoxyde d'azote : étude sur banc et évaluation de la pratique clinique.

OBJECTIVE: To evaluate the risk of over-inflation of endotracheal tube cuffs (ETC) when used with nitrous oxide (N(2)O); to assess the rate of under and over-inflation of ETC when they are inflated without a manometer; to survey anesthesiologists about how they prevent these risks. METHODS: Nine types of endotracheal tube were studied on bench using various N(2)O concentrations; airway pressure levels and two sizes of trachea. Then, the rate and magnitude of over and under inflation pressure of ETC was assessed in our clinical practice. Finally, a national survey assessed how anesthesiologists prevented misuse of endotracheal tube with N(2)O. RESULTS: Pressure in ETC rose sharply using N(2)O, up to more than 40 cmH(2)O in six over nine tube types. Only two tube types (Mallinckrodt Hi-Lo Brandt and Lanz) were immune regarding N(2)O. Pratice study showed that ETC over inflation (>30 cmH(2)O) and under inflation (<20 cmH(2)O) was observed in 50 and 31 % of patients, respectively when cuff was inflated without a manometer. In France, a minority of anesthesiologists inflated ETC with a manometer (41 %) because in 61 % of theatres only manometers were available. CONCLUSION: There are risks induced by the use of N(2)O with tracheal tubes. This study provides data to sensitize users to these risks.

Continuous care and empathic anaesthesiologist attitude in the preoperative period: impact on patient anxiety and satisfaction.

BACKGROUND: Continuous care (one anaesthesiologist per patient) and anaesthesiologist empathy at the preoperative visit could affect patient anxiety and satisfaction. We tested both unproven issues in a population at increased risk of anxiety and dissatisfaction. METHODS: In this single-blinded single-centre study, 136 women undergoing gynaecologic day-care surgery were sequentially randomized into four groups: (i) preoperative visit by an anaesthesiologist with either an empathic or a neutral attitude, and (ii) receiving either continuous or divided care (preoperative visit and anaesthesia performed by two different anaesthesiologists). Preoperative anxiety and wish for information were rated before and after the preoperative visit. Patient appraisal of the anaesthesiologist's attitude and the quality of care provided was obtained in the operating theatre. RESULTS: An empathic attitude at the preoperative visit significantly improved the perception of both the anaesthesiologist attitude (P<0.001) and the quality of information delivered (P<0.001), compared with a neutral anaesthesiologist attitude. Empathic attitude tended to decrease patient anxiety. In the operating theatre, patients who had the same anaesthesiologist (continuous care) exhibited greater satisfaction levels regarding anaesthesiologist behaviour and quality of care (P<0.001). Principal component analysis confirmed these findings, revealing that an empathic preoperative visit was linked to a reduction in preoperative patient anxiety. CONCLUSIONS: The 'one patient, one anaesthesiologist' model, in addition to ensuring sufficient time for open discussion and questions at the preoperative visit, improved patient satisfaction.

[High fidelity simulation in Anesthesia and Intensive Care: context and opinion of performing centres--a survey by the French College of Anesthesiologists and Intensivists]. / La simulation en anesthésie réanimation: profil et point de vue des centres français--une enquête du Collège français des anesthésistes réanimateurs.

OBJECTIVES: High fidelity simulation is rapidly expanding in France. The question of knowing how to accredit this new mode of continuous education and how far it is available for this purpose is pending. The purpose of this survey was to collect how active centres operate and which criteria they would prefer to accredit this form of continuing medical education. STUDY DESIGN: National survey. METHODS: A questionnaire was sent to all centres using high fidelity simulation in France (December 2009). RESULTS: Eighteen of 21 centres answered (86%; all university hospitals). These centres are equipped with adult high fidelity simulation and procedural heads for intubation. Funding is achieved via multiple sources and one third of centres benefit from manufacturers' lending. Centres are mostly located within the university premises (70%). One or more staff practitioners are involved in 78% and the majority of centres are operated by more than three. Nurse anaesthetists are not involved in most centres. Operating procedures are similar and high fidelity simulation is mostly used for in-site resident training. At present, centres are only marginally able to train non-resident senior anaesthesiologists. Sessions extend over one day (72%). The majority of centres is prone to share scenarios (75%) and pedagogic aids (93%). Basic scenarios (e.g., cardiopulmonary resuscitation) are mainstream objectives for 85% of centres. CONCLUSION: high fidelity simulation is rapidly expending in France but its ability to contribute to continuous medical education is still limited to date.

Perineal infiltration with lidocaine 1%, ropivacaine 0.75%, or placebo for episiotomy repair in parturients who received epidural labor analgesia: a double-blind randomized study.

BACKGROUND: Episiotomies are performed in approximately 20% of vaginal deliveries and may result in postpartum pain. Perineal infiltration with lidocaine during the episiotomy is widely used, despite an early study showing no difference when compared with saline. Ropivacaine has increasingly been used in the obstetric setting, although not for episiotomies. We sought to compare the analgesic efficacy of ropivacaine, lidocaine or saline for perineal infiltration before repair of a mediolateral episiotomy in patients who delivered with epidural labor analgesia. METHODS: In this double-blind randomized prospective study, infiltration with 15 mL of 0.75% ropivacaine, 1% lidocaine, or saline was performed immediately before initiating the perineal repair. During the first 24 h, the time to the first oral analgesic, analgesic intake, visual analog scale scores for pain, and patient satisfaction scores were recorded. RESULTS: A total of 154 patients were included. Demographic data were comparable between the groups. Time to first oral analgesic request was 13.9h with 0.75% ropivacaine, 17.0 h with 1% lidocaine, and 16.6 h with saline (P=0.104); the proportion of patients who did not request oral analgesics were 35%, 54% and 53%, respectively (P=0.09). Visual analog pain scores were low and not different between the three groups (ropivacaine 16.8+/-11.6, lidocaine 12.4+/-9.7; and saline 16.2+/-11.5, P=0.08). CONCLUSION: For the first 24 h, perineal infiltration of ropivacaine, lidocaine, and saline were equivalent in producing post-episiotomy analgesia.

BIS response to tamponade and dobutamine in swine varies with hypnotic/opiate ratio.

OBJECTIVES: This study in swine assessed BIS stability in response to decreases and increases in cardiac output under two propofol/remifentanil dosage combinations, both producing the same depth of surgical anaesthesia. METHODS: Eight anaesthetized-paralyzed ventilated adult swine were studied using a random-order cross-over design. Four received a P low/R high combination (P, 8.4+/-0.9 mg/kg/h; and R, 0.54+/-0.02 microg/kg/min) and then a P high/R low combination (P, 26.7+/-2.1mg/kg/h; and R, 0.34+/-0.01 microg/kg/min). The other four had these two combinations in the reverse order. Under each P/R combination, and after a 60-minutes steady state, a 15-minute stable cardiac tamponade was induced by intrapericardial gelatine infusion. Then, after returning to pre tamponade condition, a 15 minutes period with dobutamine was allowed. RESULTS: Tamponade induced falls in average mean arterial pressure (MAP) (from 79+/-18 to 47+/-9 mm Hg; p<0.05) and cardiac output (Qc) (from 1.90+/-0.46 l/min to 1.20+/-0.38 l/min, p<0.05). Conversely, dobutamine increased both MAP and Qc (p<0.05). During each type of hemodynamic challenges, changes in anaesthesia depth as assessed by BIS differed dramatically between the two drug combinations, despite observing the same percent change in P and R effect-site concentration. With P high/R low and tamponade, BIS fell from 65+/-5 to 29+/-10 (p<0.05); dobutamine produced opposite effects. With P low/R high, in contrast, BIS was not influenced by either of the hemodynamic challenges. CONCLUSION: Conversely to a high propofol/low remifentanil combination, a low propofol/high remifentanil combination allows constant anaesthetic depth in the face of haemodynamic challenges.

[Arteriovenous difference in O2 content, pulmonary venous O2 saturation, cardiac index: are they equivalent in cardiac surgery?]. / Différence artérioveineuse du contenu en O2, saturation veineuse mêlée en O2 ou index cardiaque en postopératoire de chirurgie cardiaque : sont-ils équivalents ?

OBJECTIVE: To study the concordance of cardiac index (CI), mixed venous oxygen saturation (SvO(2)) and the arterial-mixed venous O(2) content difference, i.e.: C(a-v)O(2), postoperatively to cardiac surgery. We hypothesized that significant discrepancies would be measurable between C(a-v)O(2) and SvO(2), and CI, because the latter two indices encompass less metabolic components than the former. DESIGN: Analysis of variables collected as part of routine care. PATIENTS: Eighty anesthetized patients receiving mechanical ventilation after heart surgery. MEASUREMENTS AND RESULTS: Using linear regression of SvO(2) versus C(a-v)O(2) (Reg 1) and CI versus C(a-v)O(2) (Reg 2), respectively we found that CI=2.2 L min(-1)m(-2) and SvO(2)=70% were equivalent to C(a-v)O(2)=5 ml/100ml. The error reflected by the vertical scatter of points around the regression line, once normalized was 3.24 times greater in Reg 2 than in Reg 1. CONCLUSIONS: The correspondence of CI, SvO(2) and C(a-v)O(2) values observed in a population of patients studied immediately after scheduled heart surgery match those reported in critically ill patients. SvO(2) and furthermore CI induced a sizeable scatter of points around regression line. Accordingly, they appear as a lesser estimate of the flow/metabolism balance that may at best be inferred from C(a-v)O(2).

[Field 4. Environmental safety practice in the intensive care unit. French-speaking Society of Intensive Care. French Society of Anesthesia and Resuscitation]. / Champ 4. Sécurisation du matériel en réanimation. SRLF. SFAR.

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.

[Audit of the prehospital management of severe head injured patients in the "Pays-de-la-Loire" region]. / Evaluation de la régulation préhospitalière et prise en charge initiale des traumatisés crâniens graves dans la région des Pays-de-la-Loire Etude prospective, multicentrique.

OBJECTIVE: To study severe head injured patients (SHIP) during prehospital emergency care (Samu) and the first day in the French Pays-de-la-Loire area, in 2005. STUDY DESIGN: Prospective and multicenter. PATIENTS AND METHODS: All patients managed by Samu with GCS

Quality of anaesthesia-related information accessed via Internet searches.

BACKGROUND: We conducted a study to examine the quality and stability of information available from the Internet on four anaesthesia-related topics. METHODS: In January 2006, we searched using four key words (porphyria, scleroderma, transfusion risk, and epidural analgesia risk) with five search engines (Google, HotBot, AltaVista, Excite, and Yahoo). We used a published scoring system (NetScoring) to evaluate the first 15 sites identified by each of these 20 searches. We also used a simple four-point scale to assess the first 100 sites in the Google search on one of our four topics ('epidural analgesia risk'). In November 2006, we conducted a second evaluation, using three search engines (Google, AltaVista, and Yahoo) with 14 synonyms for 'epidural analgesia risk'. RESULTS: The five search engines performed similarly. NetScoring scores were lower for transfusion risk (P < 0.001). One or more high-quality sites was identified consistently among the first 15 sites in each search. Quality scored using the simple scale correlated closely with medical content and design by NetScoring and with the number of references (P < 0.05). Synonyms of 'epidural analgesia risk' yielded similar results. The quality of accessed information improved somewhat over the 11 month period with Yahoo and AltaVista, but declined with Google. CONCLUSIONS: The Internet is a valuable tool for obtaining medical information, but the quality of websites varies between different topics. A simple rating scale may facilitate the quality scoring on individual websites. Differences in precise search terms used for a given topic did not appear to affect the quality of the information obtained.

Implementation of a weaning algorithm in postoperative cardiac ICU: simple enough to be implemented in a ventilator software.

OBJECTIVE: The aim of this study was to test the efficacy of a respiratory weaning algorithm (WA) in postoperative cardiac surgery patients. This algorithm was made simple enough to be implemented in medium-end ventilator software. PATIENTS: Twenty consecutive postoperative patients who underwent scheduled cardiac surgery with normal postoperative haemodynamic and respiratory status. METHODS: A 3 step WA (Controlled Mode Ventilation, Pressure Support (PS) at +20 cmH2O and at +10 cmH2O) was applied every 15 minute by the same investigator. A 15 minute period of respiratory stability at one step led to commute to a step ahead until patient was judged "ready for extubation" (RFE, i.e. stable during 15 min under PS +10 cmH2O). Once reaching this time, the patient was left under PS +10 until nurse and doctors in charge decided extubation according to our routine clinical criteria. RESULTS: the patients were routinely extubated, in average 187+/-169 min later than when judged RFE by the algorithm. Heart rate (P<0.05) and mean arterial pressure rose when they reached the time of effective extubation, by comparison to the RFE time point. CONCLUSION: A WA has clinical advantage in cardiac surgery as it reduces respiratory weaning duration. It helps to avoiding haemodynamic stress related to delayed extubation. Such an algorithm is simple enough to be implemented in medium-end ventilators.