[About safety parameters for patient-controlled analgesia (PCA) devices]. / À propos des paramètres de sécurité des pompes d'analgésie contrôlée par le patient (PCA).

During the course of preparation of an opioid prescription, the nurse in charge became aware that the patient-controlled analgesia (PCA) syringe driver did not permit programming for the delivery as required: a maximum bolus number (Bmax) was indicated but only a maximum cumulative dose (Dcmax) could be programmed. The prescription dose criteria were consistent with the guidelines of the French societies of palliative care, anesthesiology, and reanimation (Société française d'accompagnement et de soins palliatifs [Sfap] and Société française d'anesthésie réanimation [Sfar]). A Dcmax dose simulation was programmed and used in order to test this problem. This highlighted the following four defects: bolus delivery is not controlled, leading to potential overdose. When Dcmax is reached, the continuous flow stops, triggering an end dose failure and a new programming step is needed to restart infusion, increasing the risk of programming errors. Human intervention is required to stop the alarm, identify and solve the problem. Finally, Dcmax leads to random dose delivery in place of the predictability of dose delivery expected for opioid administration. On the other hand, Bmax is a limited dose, administered only as a bolus and regulated by the lockout interval. When the Bmax dose is reached, no alarm is triggered, the basal flow continues, but no additional doses can be delivered. Bmax and Dcmax systems are not interchangeable. No comparative study between Bmax and Dcmax could be found, and Sfap and Sfar guidelines are not precise and did not take into consideration the safety aspects of dose delivery however some facts tend to prefer that Bmax. Most of the syringe driver devices are configured for the Dcmax, but not all of them, and the physician is often forced to use the parameter of the available device restricting the choice between Bmax and Dcmax. This is not justified, whether by scientific evidence, industrial, manufacturing or commercial standards. It becomes only a technical option that does not promote standardization of dose delivery and compromises the main safety feature of PCA.

[Locoregional analgesia in palliative care: a 4-year survey]. / Analgésie locorégionale en soins palliatifs : bilan de quatre années d'utilisation.

UNLABELLED: It could append that patient pain relief in palliative care is not achieved despite the use of opioids and the multimodal approach. Therefore, regional techniques are used in the palliative care unit of the Limoges University Hospital since four years. PATIENTS AND METHODS: From October 2006 to September 2010, every patient under regional technique was followed with a specific form. The items collected were demographic characteristics, underlying disease, and associated treatments. The efficacy of regional techniques on pain was scored. RESULTS: Sixty-three patients, 39 males and 24 females, mean age 59 years, were treated by 104 regional procedures. There were 49 neuroaxial analgesia (40 spinal and nine epidural), 39 peripheral nerve blocks including 25 iliofascial blocks and 16 blocks for nerves of the scalp, face and neck. In 67.5% of the cases, the regional techniques provided adequate pain relief. For 24% of the cases, the results were uncompleted. Regional techniques were unsuccessful in 8.5%. CONCLUSION: Despite this underperformance in terms of pain control, a multicenter study is ongoing to evaluate the improvement of quality of life induced by the regional techniques.

Thrombelastogram reveals hypercoagulability after administration of gelatin solution.

We have compared the effects of gelatin, low molecular weight hydroxyethyl starch (HES) or albumin on tests of haemostasis and on the thrombelastogram in 42 ASA I patients undergoing total hip or knee replacement. Patients were allocated randomly to receive one of the three blood substitutes to obtain moderate intraoperative haemodilution. Blood loss and packed red cell infusion was the same in each group. A greater amount of gelatin was given (1.5 times the measured blood loss) because of its shorter half-life. There was a statistically significant but clinically negligible decrease in platelets count, prothrombin time and fibrinogen, and an increase in bleeding time in all groups. Platelets were slightly but significantly lower after HES. Haemodilution was comparable between groups. TEG showed a state of hypercoagulability in the gelatin group with a significant decrease in r, r + k and an increase in alpha angle.

[Prescribing and performing autologous blood transfusion: experience at a University Medical Center]. / Prescription et réalisation de la transfusion autologue différée: expérience d'un Centre Hospitalier Universitaire.

Prescription and carrying out of autologous blood transfusion in a university hospital during a whole year (1992) were investigated. 554 patients were involved. 88% of them gave at least one blood unit. Three surgical groups are specified: cardiac surgery with bypass (95 patients), orthopaedic procedures with knee or hip replacement or spine surgery (276 patients) and other types of surgery (117 patients). Prescriptions of blood donation before cardiac surgery were not carried out (by the transfusion centre) twice more often than in the other groups. This is why autologous blood taking is now effected in the anaesthetic unit. 88.9% (n = 434) of all patients did not receive homologous blood (90% in the orthopaedic group, 84% in the cardiac group). 25% of the collected units were not transfused. This figure is only 8% for the cardiac patients. An efficiency index is suggested taking in account the transfusion of autologous blood units and the need of homologous transfusion: % autologous used units x % procedures realized without homologous blood. The good rate to achieve could be 70%. In aorto-coronary bypass surgery when no autologous blood was collected preoperatively, 57.5% patients received homologous blood vs 16% when at least one unit was predeposited. A short review of literature shows an increasing place of predeposited autotransfusion, with some limits in orthopaedic surgery where a combination of autologous blood donation and other erythrocytes saving methods appears to give the best results. Erythropoietin, critical haemoglobine concentration threshold, autologous transfusion in cancer patients still need further studies.

[Techniques of autologous transfusion in hip surgery: a retrospective study]. / Techniques de transfusion autologue dans la chirurgie de la hanche: étude rétrospective.

A retrospective study was carried out on 99 patients undergoing hip surgery to evaluate the efficacy of three autotransfusion techniques on sparing of homologous blood. Preoperative normovolemic hemodilution (HDN), delayed autotransfusion (ATD) and recuperation of blood lost during surgery (RSPO) were studied. Patients were divided into 5 groups: group HDN, group ATD, group ATD + HDN, group RSPO, and the control group. The hematocrit was followed intra and postoperatively within these five groups, and mean values homologous blood transfusions calculated for each group. Comparison of mean values was performed using variance analysis (p less than 0.02). The association of delayed autotransfusion and preoperative hemodilution was most effective in sparing homologous blood (0.11 +/- 0.3 unit, p less than 0.02): however these results were obtained with a substantial drop in hematocrit which fell well below the 30% minimal accepted value at the end of the operation. There was no significant difference between delayed autotransfusion (0.35 +/- 0.8 unit) and preoperative hemodilution (0.7 +/- .01 unit) in sparing homologous blood. Hematocrit values with delayed autotransfusion were greater than these obtained with preoperative hemodilution. The difference was significant at the beginning of the operation (p less than 0.001), but not significant at the end. Recuperation of blood lost during surgery was least effective in sparing homologous blood (1 +/- 1.2 unit, p less than 0.02). Because of the moderate decrease in hematocrit, there are very few contraindications to delayed autotransfusion. Recuperation of blood lost during surgery should be associated with another autotransfusion technique.(ABSTRACT TRUNCATED AT 250 WORDS)