Factors predicting the cost of endovascular management of intracranial aneurysms.

INTRODUCTION: The management of intracranial aneurysms has evolved in the recent years, and endovascular coiling has become the first treatment option in many countries. In Tunisia, this neuroendovascular treatment meets a progressive but slow development, slowed down, by the economic component. AIM: This study aimed to evaluate the global cost of endovascular treatment of cerebral aneurysms and determine the factors influencing the variation of direct medical cost. METHODS: A prospective study including patients who underwent interventional neuroradiology procedures for intracranial aneurysms between March 2019 and June 2019. Total cost (direct medical and non medical cost) was assessed using the micro-costing method. Statistical analysis (descriptive followed by a multivariate analysis) was performed by PSPP software with a p-value< 0.05 considered statistically significant. RESULTS: Twenty-nine patients were included (mean age 54±14 years). The average overall cost of treatment was 15 877 DT (5 081€), ranging from 8 005 DT (2 562 €) to 36 325 DT (11 624 €). The average cost of medical devices used during the procedure was 13 548 DT (4 335 €) which represents 85.3% of the total cost. The direct medical cost was particularly influenced by aneurysm's and neck's size, and by the total cost of coils. CONCLUSIONS: The medical devices used during the procedure greatly influenced the direct medical cost of the management of intracranial aneurysms.

Errors in preparation and administration of parenteral drugs in neonatology: evaluation and corrective actions.

BACKGROUND: The medication iatrogenic risk is quite unevaluated in neonatology Objective: Assessment of errors that occurred during the preparation and administration of injectable medicines in a neonatal unit in order to implement corrective actions to reduce the occurrence of these errors. METHODS: A prospective, observational study was performed in a neonatal unit over a period of one month. The practice of preparing and administering injectable medications were identified through a standardized data collection form. These practices were compared with summaries of the characteristics of each product (RCP) and the bibliography. RESULTS: One hundred preparations were observed of 13 different drugs. 85 errors during preparations and administration steps were detected. These errors were divided into preparation errors in 59% of cases such as changing the dilution protocol (32%), the use of bad solvent (11%) and administration errors in 41% of cases as errors timing of administration (18%) or omission of administration (9%). CONCLUSION: This study showed a high rate of errors during stages of preparation and administration of injectable drugs. In order to optimize the care of newborns and reduce the risk of medication errors, corrective actions have been implemented through the establishment of a quality assurance system which consisted of the development of injectable drugs preparation procedures, the introduction of a labeling system and staff training.

Propofol, midazolam, vancomycin and cyclosporine therapeutic drug monitoring in extracorporeal membrane oxygenation circuits primed with whole human blood.

INTRODUCTION: As a result of drug sequestration and increased volume of distribution, the extracorporeal membrane oxygenation (ECMO) procedure might lead to a decrease in drug concentrations during a patient's treatment. The aim of this study was to evaluate sedative, antibiotic and immunosuppressive drug loss in ECMO circuit using ex-vivo and in-vitro experiments. METHODS: Blood concentrations of propofol, midazolam, cyclosporine and vancomycin were measured in an ex-vivo ECMO circuit primed with whole human blood, and compared to controls stored in polypropylene tubes. In vitro experiments were also conducted to further explore the role of temperature, oxygen exposure and polyvinylchloride surfaces on propofol loss in the ECMO circuit. RESULTS: Propofol concentration decreased rapidly; 70% of its baseline concentration was lost after only 30 minutes, and only 11% remained after five hours (P <0.001 for the comparison with control polypropylene tube propofol concentration). Further experiments demonstrated that oxygen exposure and contact with polyvinylchloride tubing were respectively responsible for 70% and 85% of propofol loss after 45 minutes. Midazolam concentration also rapidly decreased in the ECMO circuit, with only 54% and 11% of baseline concentration being detected at 30 minutes and 24 hours respectively (P = 0.01 versus control). Alternatively, cyclosporine concentration remained stable for the five first hours, then decreased to 78% and 73% of the baseline value after 24 hours and 48 hours, (P = 0.35 versus control). Lastly, vancomycin concentration remained stable in the ECMO circuit for the 48-hour experimental protocol. CONCLUSIONS: We observed important losses of propofol and midazolam, while cyclosporine concentration decreased slowly and moderately, and vancomycin concentration remained unchanged in the ex-vivo ECMO circuit primed with whole human blood. These data might help intensive care unit physicians planning clinical trials with a final objective to better adapt doses of these drugs while treating critically ill ECMO patients.

[Impact of ECMO on drugs pharmacokinetics]. / Impact de l'ECMO sur la pharmacocinétique des médicaments.

Extracorporeal membrane oxygenation (ECMO) is a life support system used in the treatment of patients of all ages with severe respiratory or cardiorespiratory failure. Despite the intensive use of drugs in the treatment of patients on ECMO, few studies have been conducted to determine the impact of this device on the pharmacokinetics of drugs. Publications in this field have shown pharmacokinetics changes resulting in an increase in volume of distribution of drugs and/or decreased clearance with consequent increase of their half-life. Reduced plasma concentrations of some drugs due to their adsorption on the different components of the circuit further complicates the determination of pharmacokinetic parameters of patients treated by ECMO. The literature published up to now on the pharmacokinetic changes associated with ECMO provide preliminary support for dosage adjustment. However, more research is needed to identify dosage strategies for this patient population.