Strategy to secure the neuraxial route in anaesthesia: Risk mapping and feedback from the application of the ISO 80369-6 standard NRFit® connectors.

INTRODUCTION: In anesthesia, a medication error would occur every 20 to 133 anesthesia procedures, and 14% is related to a route administration error. To secure neuraxial route, ISO group published a norm in 2016 to develop specific connectors, the "NRFit® connector". The main objective of this work, is to develop a risk mapping related to neuraxial medication errors therefore prepare the NRFit® implementation in anesthesia units in a French Universitary Hospital. METHODS: Failure modes, effects and criticality analysis (FMECA) methodology was used for our risk mapping which was divided in 3 anesthesia specialities. For each, the analysis was performed for accidental neuraxial administration of intravenous drugs, and its opposite error. Secondly, NRFit® devices were tested for 1 month by 3 experimented anesthetists. RESULTS: The majority of reported errors concerns epidural and intrathecal anesthesia, and more frequently in the field of obstetrics. Opioids and tranexamic acid, administered in neuraxial route, are drugs with the highest criticality. The tests were rather conclusive and made it possible to highlight the additional needs in medical devices. DISCUSSION: Obstetrics is the riskiest area due to the frequency of epidural anesthesia, the administration of critical drugs in intravenous and neuraxial route. This work increased the awareness of our group, improved the measure of this risk and harmonized practices. CONCLUSION: This work is the first step of the project to prevent administration route error in anesthesia during patient's drug management. The next step will be the NRFit® implementation for epidural and combined spinal-epidural anesthesia in our hospital.

How a Patient Personalised Clinical Pharmacy Programme Can Secure Therapeutic Care in an Orthogeriatric Care Pathway (5P Project)?

BACKGROUND: A new model was developed for integrating a personalised clinical pharmacy programme (5P project) into the orthogeriatric care pathway. OBJECTIVE: To secure the therapeutic care of orthogeriatric patients. DESIGN AND SETTING: Prospective descriptive study in a multisite teaching hospital from June 2019 to January 2020. SUBJECTS: Patients aged ≥75 years admitted for hip fracture. METHODS: A prescription review was performed for all patients at inclusion. Other clinical pharmacy activities (additional prescription review, pharmaceutical interviews, medication reconciliation) were dedicated to "high-risk" patients. Potential medication errors (ME), either pharmaceutical interventions (PI) or unintentional discrepancies (UID), were recorded. The potential clinical impact of PI was evaluated by a pluriprofessional expert panel using a validated tool. RESULTS: In the 455 patients included, 955 potential ME were detected, that is ≥1 potential ME for 324/455 (71%) patients. In acute care, 561 PI were formulated during prescription review for 440/455 (97%) patients and 348/561 (62%) were accepted by physicians. Medication reconciliation was performed for 213 patients, 316 UID were identified. In rehabilitation units, a second prescription review was performed for 112/122 (92%) "high-risk" patients, leading to 61 PI. The clinical impact was evaluated for 519/622 (83%) PI. A consensus was obtained for 310/519 (60%) PI: 147/310 (47%) were rated as having minor clinical impact, 138/310 (45%) moderate, 22/310 (7%) major, 2/310 (0.6%) vital, and 1/310 (0.3%) null. CONCLUSION: The 5P project secured the orthogeriatric care pathway by detecting a great number of potential ME, including PI mostly considered as having a significant clinical impact.

Tinnitus and Associated Handicaps in the French Mountain Artillery: Assessment by the Tinnitus Handicap Inventory.

INTRODUCTION: Tinnitus and associated handicap related to acoustic trauma sequelae have never been assessed in the French artillery. Although impulsive noise exposure to firearms and canons are thought to increase prevalence of tinnitus among soldiers, recent studies demonstrating this fact are missing. MATERIALS AND METHODS: Here, a representative sample of 389 soldiers from an operational mountain artillery regiment was surveyed. Soldiers personally concerned by tinnitus were invited to fill in a questionnaire. We assessed tinnitus and the associated handicap using a French translation of the Tinnitus Handicap Inventory (THI). Questions about attention/concentration problems, impaired speech hearing and understanding, sleep disorders, social and familial tension, irritability, depression, and tiredness as linked to tinnitus were the core of the questionnaire. RESULTS: Soldiers that completed the THI (n = 73, 19%) had a mean THI score of 18 ± 17, this mean score corresponded to a mild handicap. At this grade, tinnitus should be easily masked and should not interfere with daily activities. The percentage of soldiers concerned by tinnitus was slightly higher in the older age class, but there was no significant difference of THI scores between the different age classes. The most reported handicaps were attention/concentration problems, impaired speech hearing, and understanding. Among the THI fillers, eight soldiers (11%) had THI scores >36, indicating a moderate to severe handicap. CONCLUSION: Despite a mild tinnitus handicap, the percentage of people concerned by tinnitus in this regiment is higher (19%) than that in the estimated percentage of general population of European countries (about 10%). It should be of interest to replicate this type of study from other regiments and from other countries. Education and good fitting of hearing protection for prevention of acoustic trauma sequelae should still be encouraged.

Specific activation of operculum 3 (OP3) brain region during provoked tinnitus-related phantom auditory perceptions in humans.

The phantom sound perception mechanism by which a sound perception occurs without any external sound source is still enigmatic. According to our previous fMRI study, a small region in the parietal operculum 3 was hyperactivated as a function of tinnitus periodicity in subjects with acoustic trauma tinnitus sequelae. This region was localized in the vicinity of neural correlates of middle-ear tympano-ossicular chain movements due to pressure variations. Disturbed proprioceptors are known to trigger illusory perceptions; therefore, we hypothesized that a disturbance of middle-ear proprioceptors may originate phantom sound perceptions. We designed an fMRI study that aimed to stimulate middle-ear proprioceptors by repetitive vibrations using various rates of click trains. In this study, we report that exposure to specific rates of stimuli for a few minutes at comfortable intensity level in healthy subjects distinctly triggered transient tinnitus-like aftereffects. The fMRI neural correlates of the aftereffects were unequivocally localized in the same parietal region as in acoustic trauma tinnitus sufferers. Our results strongly suggest that a middle-ear kinesthetic/proprioceptive illusion exists at the origin of acoustic trauma tinnitus via a somatosensory pathway encompassing the trigeminal system.

Otosclerosis and Fitness to Fly.

BACKGROUND: When an aircrew member is referred for otosclerosis, his flight fitness may be questionable. The objective of this retrospective study was to describe a case series of otosclerosis in an aircrew population and to discuss the decisions about their flight waivers. METHODS: There were 27 aircrew members who were referred to the ENT-Head and Neck Surgery Department of the National Pilot Expertise Center. Their medical files were retrospectively examined. RESULTS: Out of 16 patients who had surgery, 2 did not obtain a flight fitness waiver afterwards. Among the 14 who received waivers, 12 had no restrictions on their flight fitness. Among the nonoperated patients, 1 of 11 did not obtain a waiver. Seven patients were declared medically fit to fly without a waiver and three obtained a waiver. DISCUSSION: Fitness was based on auditory and balance statuses and the follow-up of these findings. A postoperative CT-scan and the operative report were used to determine the quality of stapes surgery. Professional speech audiometry in noise might be as interesting. The results made it possible to determine a patient's fitness to fly with a waiver, which is more or less associated with restrictions. In our series, only 3 aircrew members out of 27 did not obtain a flight fitness waiver. The few published studies on the resumption of flight for patients who underwent surgery and our experience in France with similar waivers in commercial and military aviation suggest that under certain conditions and after relevant vestibulocochlear assessment, stapes surgery may allow for a safe recovery of aviation activity.

Use of a Fogarty catheter after tracheobronchial inhalation of a bead.

We describe a case of tracheobronchial inhalation of a bead by a five-year-old girl in Djibouti. The bead was extracted using a Fogarty balloon catheter passed through the rigid bronchoscope without complication. This kind of accident is not exceptional and we discuss the management of such cases with limited diagnostic tools and therapeutic environments.

Relevance of 5 different imaging signs in the evaluation of carotid artery invasion by cervical lymphadenopathy in head and neck squamous cell carcinoma.

OBJECTIVE: The aim of this retrospective study was to determine the relevance of 5 different imaging signs in the evaluation of carotid artery invasion. SUBJECTS AND METHODS: Between September 2001 and September 2008, 22 patients (20 men and 2 women) presented with lymph node metastasis of a head and neck squamous cell carcinoma that invaded the carotid artery. The patients received either carotid artery dissection (CAD, group 1 [n = 17]) or carotid resection (group 2 [n = 5]). Preoperative images using CT (n = 18) and/or MRI (n = 14) were analyzed. RESULTS: In 1 of 17 cases in group 1 and in 5 of 5 cases in group 2, encasement of more than 180 degrees of the artery was present (P < .05). Segmental obliteration of the fat between the lymph node and the carotid artery was noted in 7 of 17 cases in group 1 and for all cases in group 2 (P < .05). Deformation of the carotid artery was reported in no cases in group 1 and in all cases in group 2 (P < .05). CONCLUSION: The combination of deformation of the carotid artery, encasement of more than 180 degrees of the carotid perimeter, and segmental obliteration of the fat between the adenopathy and the carotid artery was highly predictive of massive invasion of the carotid artery, which would require a resection en bloc. In comparison, the isolated existence of encasement of more than 180 degrees or segmental obliteration of fat could not strictly indicate massive invasion of the carotid artery; thus, CAD could be planned.

Comparison of LigaSure vessel sealing system, harmonic scalpel, and conventional hemostasis in total thyroidectomy.

OBJECTIVE: The aim of the study was to compare the efficiency, safety, and cost of the different methods of hemostasis (conventional hemostasis versus LigaSure vessel sealing system [LVSS] versus harmonic scalpel) currently available for thyroid surgery. STUDY DESIGN: Randomized, controlled trial. SETTING: The study was conducted from September 2007 to December 2008 in a university hospital. PATIENTS AND METHODS: Sixty patients (48 females and 12 males) underwent a total thyroidectomy for multinodular goiter. They were randomly assigned into three groups: group one (n = 20), conventional hemostasis; group two (n = 20), LigaSure; and group three (n = 20), harmonic scalpel. RESULTS: For group three, the mean operative time was 37 minutes shorter than group one (P < 0.001) and eight minutes shorter than group two (P = 0.04). The complications rate was similar among the three groups. The mean postoperative paracetamol consummation in group one was 1.4 g greater than in group two (P = 0.016) and 1.3 g greater than in group three (P = 0.02). The overall average operative cost was 11 and 85 dollars cheaper for groups two and three than for group one, respectively (P < 0.001). CONCLUSION: Total thyroidectomy using the harmonic scalpel was the fastest procedure because it was bloodless, and hemostasis and sectioning were controlled with a single instrument; it was, therefore, the most inexpensive procedure because of the reduction of operative time and staff cost. The operative safety was similar for all three procedures. In our series, the harmonic scalpel and the LVSS caused less pain than the conventional hemostasis.

Ultrasonic partial glossectomy.

INTRODUCTION: Partial glossectomy is the main treatment for tongue carcinoma. The resection of the tongue, which is a very vascularised tissue, requires a good hemostasis. The advantage of the harmonic scalpel is in combining sectioning and hemostasis in one single instrument, allowing a bloodless dissection of soft tissue. The aim of this prospective study was to evaluate the benefits and risks when using a harmonic scalpel in partial glossectomy. SUBJECTS AND METHODS: In this prospective study conducted in a university hospital from march 2004 to December 2008, eighteen consecutive patients underwent a partial glossectomy with the use of harmonic scalpel. Results were compared with previous surgical procedures performed between September 2000 and February 2004 by monopolar hemostasis by our team (n = 12) when the harmonic scalpel was not available. RESULTS: All 18 patients underwent partial glossectomy with the harmonic scalpel as the only instrument of section and hemostasis. The median blood loss was of 0 mL. The median operative time was 29 minutes (16 minutes less than partial glossectomies performed with conventional hemostasis. P < .001). No operative complications occurred. Two post-operative bleedings (5 days and 7 days after the glossectomy) occurred necessitating a new surgery to ligate the lingual artery. The margins of the resection were acceptable and no recurrence appeared. CONCLUSION: The harmonic scalpel makes it fast and easy to perform a partial glossectomy with no bleeding. Ligation of the lingual artery (when it is visualized during the dissection) should be performed because of the frequency (more than 10% in our series) and because of the potential gravity of a lingual post-operative bleeding.