[Postoperative pain management on surgical wards in one university hospital: short- and medium-term effects of a quality assurance program]. / Evaluation à court et à moyen terme d'une démarche qualité pour la prise en charge de la douleur postopératoire dans un CHU.

OBJECTIVES: Evaluation of the short- and medium-term impact of a postoperative pain management quality assurance programme in a university hospital. STUDY DESIGN: Prospective study. MATERIALS AND METHODS: In 1998: chart review and survey of patients and professionals. Principal corrective actions: support for evaluation and tracking of potentially painful surgical procedures, prescription form including an emergency treatment plan, distribution of a set of guidelines. Evaluation was identical during the quality assurance programme and three years later, in 2003. RESULTS: In 2003, information regarding postoperative analgesia was received by 70% of patients and understood by 99% (50% in 1998, p<0.001). Sixty-two percent of patients were totally satisfied with their doctors in 2003 vs 75% in 1998 (NS). Pain was documented in 63.1% of charts in 2003, vs 10% in 1998 (p<0.001). Hundred percent of doctors were aware of the analgesic protocols in 2003 vs 69% in 1998 (p<0.02). In 2003, the treatment of analgesic side effects was known by 86% of doctors vs 29% in 1998 and these effects were looked for by 57% of caregivers in 2003 vs 11% in 1998 (p<0.001). CONCLUSION: Management of postoperative pain has progress significantly and the quality indicators used for evaluation have improved. Patients are better informed, which raises standards. The programme will be extended to all other surgical departments of the hospital, under the authority of CLUDS (Committee for Pain Control and Palliative Care).

[Evaluation of the off-site preanaesthetic consult in Lorraine]. / Evaluation du réseau de consultations préanesthésiques délocalisées de Lorraine.

OBJECTIVES: To evaluate the results of Off Site preanaesthetic consult in Lorraine and to draw up a method for these pre-operative visits. STUDY DESIGN: Two surveys of the Lorraine-regional practice (from both the anaesthetists and surgeons from Lorraine) and one survey of patient satisfaction. PATIENTS AND METHOD: Questionnaires were sent by mail to all anaesthetists (n=270) and surgeons (n=339) in the Lorraine region. In the immediate postoperative period, specific questionnaires were sent by mail to selected patient groups (n=73 in each group), one group having and the other (control) not having Off Site preanaesthetic consult. RESULTS: Anaesthetists' survey: 48.4% of interviewed anaesthetists belonged to the pre-anaesthetic consult network. 81.2% of these anaesthetists performed Off Site pre-anaesthetic consult. The main recognized advantages were patient comfort (89.6%) and cost effectiveness (57.3%). 26.1% of anaesthetists who did not participate to the network were strongly opposed to this practice, while 60.9% were prepared to enter the network. Surgeons' survey: 15.6% of surgeons were not satisfied that anaesthetists in their institutions practiced the Off Site pre-anaesthetic consult. Patients' survey: no difference in satisfaction towards the quality of information delivered during the consultation (anaesthetic technique, analgesia and evaluation of the perioperative risk) nor in terms of perioperative anxiety. The average transportation distance spared by Off Site preanaesthetic Consult was 98 miles. CONCLUSION: Off Site preanaesthetic consult may have real benefits in terms of, patient satisfaction, comfort and cost-effectiveness. In the Lorraine region, a majority of anaesthetists has experience with this practice.

Recovery after prolonged anaesthesia for acoustic neuroma surgery: desflurane versus isoflurane.

In this study, 33 patients were randomly assigned to receive desflurane (D) or isoflurane (I) for acoustic neuroma surgery. The time from end of the procedure to spontaneous breathing, extubation, eye-opening, hand-squeezing to command, and ability to state name, birthdate and phone number were recorded. The Steward recovery score was also recorded every five minutes during the first 20 minutes postoperatively and then every 10 to 15 minutes. Groups were similar regarding patient characteristics, depth of anaesthesia, sufentanil total dose, anaesthesia duration (D: 349.1 +/- 19.1 min; I: 349.2 +/- 22.9 min), haemodynamic/respiratory parameters, and surgical conditions (assessed by a bleeding score). The emergence time in the D group was significantly faster than the I group (D: 14.9 +/- 2.4 min vs I: 29.2 +/- 2.4 min for eye-opening). Full recovery also occurred earlier in the D group (D: 22.1 +/- 3.1 min vs I: 37.6 +/- 4.0 min, P<0.005 for stating name). Steward recovery scores were also better during the first postoperative hour in the D group (D: 40 min vs I: 90 min, P<0.005 for 100% of patients with Steward score of 6). The results indicate that desflurane is associated with similar operating conditions and faster postoperative recovery following acoustic neuroma surgery. The faster recovery following desflurane may be desirable after long surgical procedures, enabling the patient's full cooperation and facilitating early diagnosis of any potential neurological deficit.

Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice.

These guidelines represent a consensus of experts in the field of immediate hypersensitivity reactions occurring during anaesthesia. They were based on international science, and implemented in France under the auspices of the French Society for Anaesthesia and Intensive Care (SFAR: Société Française d'Anesthésie et de Reanimation). Their aim was to provide the most valid, widely accepted, effective and easily teachable guidelines that current knowledge, research and experience can provide. This paper presents the main extracts of these recommendations with the most relevant clinical implications.

[Anaphylactic and anaphylactoid reactions occurring during anaesthesia in France. Seventh epidemiologic survey (January 2001-December 2002)]. / Epidémiologie des réactions anaphylactiques et anaphylactoïdes peranesthésiques en France. Septième enquête multicentrique (Janvier 2001-Décembre 2002).

OBJECTIVES: Hypersensitivity reactions IgE-mediated (anaphylaxis) or non-IgE-mediated (anaphylactoid) reactions occurring during anaesthesia remain a major cause of concern for anaesthesiologists, since these reactions remain usually unpredictable, may be potentially life-threatening even when appropriately treated. The authors report the results of the last 2-year survey (2001, 2002) of such reactions conducted in France by the GERAP (groupe d'etude des reactions anaphylactoides peranesthesiques), and compare these results with their previous published surveys. METHODS: Between January 1, 2001 to December 31, 2002, 712 patients who experienced immune-mediated (anaphylaxis) or non-immune-mediated (anaphylactoid) reactions were referred to one of the 40 allergo-anaesthesia centres members of the GERAP. Anaphylaxis was diagnosed on the basis of clinical history, tryptase measurements during the adverse reaction, and skin tests and/or specific IgE assay. RESULTS: Anaphylactic and anaphylactoid reactions were diagnosed in 491 cases (69%) and 221 cases (31%), respectively. The most common causes of anaphylaxis were neuromuscular blocking agents (NMBA) (n=271, 55%), latex (n=112, 22.3%), and antibiotics (n=74, 14.7%). Succinylcholine (n=102, 37.6%) and rocuronium (n=71, 26.2%) were the most frequently incriminated NMBAs. Cross-reactivity between NMBAs was observed in 63.4 % of cases of anaphylaxis to a NMBA. No difference was observed between anaphylactoid and anaphylactic reactions when the incidences of atopy, food, or drug intolerance were compared. However atopy, asthma and food allergy were significantly more frequent in case of latex allergy, when compared with NMBA allergy. Clinical manifestations were more severe in anaphylaxis. The positive predictive value of tryptase measurement for the diagnosis of anaphylaxis was 95.3%, the negative predictive value 49%. The diagnostic value of specific neuromuscular blocking agent IgE assays was confirmed. CONCLUSION: Our results further corroborate the need for systematic screening in case of immediate hypersensitivity reaction during anaesthesia and for the constitution of allergo-anaesthesia centres to provide expert advice to anaesthesiologists and allergologists.

Immediate hypersensitivity to chlorhexidine: literature review.

Chlorhexidine, an antiseptic belonging to family of biguanides, is used extensively in the medical and surgical environment. Late onset hypersensitivity and eczema occur regularly and are well documented events. Conversely, immediate hypersensitivity, sometimes taking the form of acute urticaria that can result in anaphylactic shock, is rarer. These manifestations can occur during contact of the skin or mucosa with chlorhexidine. Out of the fifty case reports of chlorhexidine-related anaphylaxis published worldwide over the past ten years, fifteen occurred during surgery. Signs generally appear from 15 to 45 minutes after the start of anesthesia. If there is any suspicion of immediate allergy to chlorhexidine, prick-tests or even intradermal reaction (IDR) techniques are highly recommended. In the event of confirmed allergy to chlorhexidine, strict eviction is required, bearing in mind that over a hundred medicinal products currently on the French market contain chlorhexidine.

Allergy and anaphylaxis in anaesthesia.

Immediate hypersensitivity reactions to anaesthetic and associated agents used during the perioperative period have been reported with increasing frequency in most developed countries. Most reactions are of immunologic origin (IgE mediated, anaphylaxis) or related to direct stimulation of histamine release (anaphylactoid reactions). The incidence of anaphylaxis is estimated between 1 in 10000 and 1 in 20000 anaesthesia, and any drug administered in the perioperative period can potentially produce life-threatening immune-mediated hypersensitivity reactions. Neuromuscular blocking agents (NMBAs), latex and antibiotics represent the most frequently involved substances. However, anaphylactic reactions cannot be clinically distinguished from non-immune mediated reactions which account for 30% to 40% of hypersensitivity reactions. Therefore, any suspected anaphylactic reaction must be extensively investigated using combined peroperative and postoperative testing to confirm the nature of the reaction, the responsibility of suspected drugs and to provide precise recommendations for future anaesthetic procedures. These investigations include plasma histamine, tryptase and specific IgE concentration determination at the time of the reaction, and skin tests 6 weeks later. In addition, since no specific treatment has been shown to reliably prevent the occurrence of anaphylaxis, allergy assessment must be performed in all high-risk patients. The need for proper epidemiological studies and the relative complexity of allergy investigation should be underscored. They represent an incentive for further development of allergo-anaesthesiology clinical networks to provide expert advice for anaesthetists and allergologists.

[Factors associated with laparoscopic approach for cholecystectomy, appendicectomy and inguinal herniorraphy in France]. / Facteurs associés à la coelioscopie dans les cholécystectomies, les appendicectomies et les cures de hernie inguinale en France.

OBJECTIVE: To determine on a national level the factors associated with the use of laparoscopy for digestive surgery. STUDY DESIGN: Nation wide study using a large representative sample (3 days of anaesthesia in France). METHODS: Univariate followed by multivariate analyses of data gathered in 1996 during the survey led by the French Society of Anaesthesia and Intensive care ("SFAR") including 2847 surgical procedures for cholecystectomy, appendicectomy or inguinal herniorraphy. RESULTS: Independent factors associated with the use of laparoscopy were: for cholecystectomy: age (less frequent when > or =71 years: adjusted Odds ratio [AOR] 0.4), sex (more frequent in female: AOR 1.7), ASA physical status (less frequent when > or =3: AOR 0.5), private hospital (AOR 2.0), procedure scheduled at least the night before (AOR 2.1), and use of closed circuit general anaesthesia (AOR 1.6); for appendectomy: age >15 years (AOR 1.9-2.2), female (AOR 2.1), private hospital (AOR 2.7), scheduled procedure (AOR 2.1), prolonged procedure (AOR 8.4), endotracheal intubation (AOR 16.7), and closed circuit (AOR 2.7); for inguinal herniorraphy: ASA physical status (less frequent when > or =3: AOR 0.4), private hospital (AOR 3.4), prolonged procedure (AOR 5.6), and endotracheal intubation (AOR 21.6). Association with a closed circuit was confirmed for general anaesthesia using a volatile agent (AOR 1.5). Overall, ambulatory surgery was rarely performed and used only for open procedures. Regional anaesthesia was used only for inguinal open herniorraphy. CONCLUSION: These data obtained from a large national survey confirmed the higher frequency of laparoscopy in middle aged patients, female (except for inguinal herniorraphy), without important comorbidity, in private hospitals. Laparoscopy was associated with prolonged procedures and with a change in the anaesthetic technique for appendicectomy and inguinal herniorraphy: tracheal intubation was almost constantly used. Whatever the procedure, closed circuit anaesthesia was more frequently used when surgery was performed under laparoscopy, reflecting newer equipment of the hospital, private or public.

[Impact of 2 strategies of analgesia on postoperative pain after emergency hand surgery performed on an ambulatory basis]. / Impact des modalités de prescriptions d'antalgiques sur la douleur postopératoire après chirurgie de la main réalisée en urgence en hospitalisation de jour.

OBJECTIVES: The assessment of the impact of various analgesic regimens on postoperative pain at home, following emergency and ambulatory hand surgery. STUDY DESIGN: Prospective comparative study of "before" and "after" groups by phone questionnaire on the first postoperative day. PATIENTS: All emergency and ambulatory surgery patients undergoing hand surgery in a specialist university hospital unit. METHODS: a) "Before" group (120 patients): analysis of current analgesic practice in the service (prescriptions by surgeon on duty), assessment of the incidence of pain scores with an intensity >/= 4 on a numerical score of 0 to 10, and identification of the most painful surgical interventions; b) formulation for these surgical interventions of multimodal analgesic protocols drown up by the anaesthetists; c) "After" group (51 patients): assessment of the efficacy of these analgesic protocols through comparison with the "before" group. RESULTS: a) "Before" group: the total incidence of pain scores with an intensity >/= 4 was 42% and in the case of conditions involving a joint or sepsis, 88%. Dextropropoxyfen-paracetamol alone was prescribed in 66% of cases and was associated with a 48% analgesic failure rate. Non-steroidal anti-inflammatory drugs were prescribed in 14% of cases, tramadol in 7% and a combination of drugs in 15%; b) "After" group: the incidence of pain scores with an intensity >/= 4 decreased to 21% in surgical interventions involving joints or sepsis (p < 0.001). CONCLUSION: Multimodal analgesic regimens are more effective than free prescriptions. This study underlines the need to further educate surgeons in this area. Despite these written protocols, there remains a 21% incidence of pain at home on day one.

[General anaesthesia for Caesarean section in a patient with pulmonary atresia and an intact intraventricular septum]. / Anesthésie pour césarienne chez une patiente atteinte d'une atrésie pulmonaire à septum interventriculaire intact.

We report the case of a 22-year-old primigravida patient presenting pulmonary atresia with intact ventricular septum, a rare congenital heart disease. Caesarean delivery was performed at 32 weeks of gestation because of moderate maternal function deterioration and foetal growth restriction. General anaesthesia was used because of the presence of lumbar Harrington rods. The administration of etomidate, celocurine and a continuous perfusion of remifentanil right from induction ensured haemodynamic stability and a rapid emergence and recovery.

[Chest pain and sulprostone during postpartum hemorrhage]. / Angor et sulprostone au cours d'une hémorragie de la délivrance.

A case of chest pain in a 31-year-old woman after vaginal delivery with epidural analgesia during sulprostone administration is described. Chest pain occurred shortly after sulprostone was started and disappeared when sulprostone was stopped. Ischaemia related data were negative. Angiographically coronary arteries were normal. Coronary artery spasm aetiology was retained. Sulprostone pharmacology is summarized. Coronary artery effects are compared with literature reports. Recommendations before sulprostone use are underlined.

Acute postoperative pain management at home after ambulatory surgery: a French pilot survey of general practitioners' views.

IMPLICATIONS: We assessed the views of French general practitioners concerning pain relief at home after ambulatory surgery in a cross-sectional prospective survey. The results revealed that there is need for improvement, mainly in prescribing more suitable analgesic protocols and optimizing postdischarge relationships between physicians.