[VENTILOP survey. Survey in peroperative mechanical ventilation]. / Enquête VENTILOP. Enquête sur la ventilation mécanique peropératoire.

INTRODUCTION: Mechanical ventilation can initiate ventilator-associated lung injury and postoperative pulmonary complications. The aim of this study was to evaluate (1) how mechanical ventilation was comprehended by anaesthetists (physician and nurses) and (2) the need for educational programs. METHODS: A computing questionnary was sent by electronic-mail to the entire anaesthetist from Alsace region in France (297 physicians), and to a pool of 99 nurse anaesthetists. Mechanical ventilation during anaesthesia was considered as optimized when low tidal volume (6-8mL) of ideal body weight was associated with positive end expiratory pressure, FiO2 less than 50%, I/E adjustment and recruitment maneuvers. RESULTS: The participation rate was 50.5% (172 professionals). Only 2.3% of professionals used the five parameters for optimized ventilation. Majority of professionals considered that mechanical ventilation adjustment influenced the patients' postoperative outcome. Majority of the professionals asked for a specific educational program in the field of mechanical ventilation. DISCUSSION: Only 2.3% of professionals optimized mechanical ventilation during anaesthesia. Guidelines and specific educational programs in the field of mechanical ventilation are widely expected.

[Specialized Studies Diploma (S.S.D): assessment of Urology and Andrology by degree candidates at Faculté des Sciences de la Santé (FSS) at Cotonou]. / Diplome d'Etudes Specialisees (D.E.S) d'Urologie- Andrologie: appreciation de la formation par les candidats au dit diplome a la Faculte des Sciences de la Sante de Cotonou.

PURPOSE: Inventory views of urologists in training on teaching of Urology and Andrology received at Cotonou. METHODS: An anonymous electronic questionnaire was sent by email to 26 doctors in training of specialized studies diploma of Urology and Andrology current month of May and June 2013. The questionnaire asked their knowledge of educational objectives, their appreciation of theoretical courses and practical training Receipts. RESULTS: 16 responses were obtained. The average age of physicians in SSD was 33.9 years± 6.14 (26 years-47 years). The sex ratio was 15 males to 1 female. The training was funded on equity by 25% of doctors. Residents had an understanding of the objectives of their training in urology and andrology: 68.7% knew the objectives of theoretical courses, 87.5% participated in organized lectures, 62.5% knew practical purposes, 93.7% knew the terms of the evaluation at the end of the year. The primary source of documentation was digital document (CD, DVD, computer, websites) 43.7%. In the weekly schedule, 75% of residents assisted consultations carried out by a senior, 93.8% attended a staff operative programming. Over a month, the frequency of assistance in the operating room as first aid procedure had a median of 4 (1 -10). One in 15 received regular debriefing following the completion of care act. The duration of hospital daily work was between 4 and 8 hours for 68.9% of the residents. CONCLUSION: Opinion of doctors in training on urological acquisitions highlights the need to support the development of specialized studies diploma inUrology and Andrology at Faculty of health sciences at Cotonou.

OBJECTIFS: Recenser l'opinion des urologues en formation sur l'enseignement d'urologie et d'andrologie reçu à Cotonou. PATIENTS ET MÉTHODES: Un questionnaire électronique anonyme a été adressé aux 26 médecins en formation du DES d'urologie andrologie courant mai et juin 2013. Le questionnaire recueillait leur connaissance des objectifs pédagogiques, leur appréciation des cours théoriques reçus et des stages pratiques. RÉSULTATS: 16 réponses ont été obtenues. La moyenne d'âge des médecins en DES était de 33,9ans± 6,14 (26ans-47ans). Le sexe ratio était de 15 hommes pour 1 femme. La formation était financée sur fonds propres par 25% des médecins. Les résidents avaient une connaissance des objectifs de leur formation en urologie et andrologie: 68,7% connaissaient les objectifs des cours théoriques. 87,5% participaient aux cours magistraux organisés. 62,5% connaissaient les objectifs pratiques. 93,7% connaissaient les modalités de l'évaluation en fin d'année. La première source de documentation était faite de document sur support numérique (CD, DVD, ordinateur, sites internet) 43,7%. Dans le calendrier hebdomadaire, 75% des résidents avaient assisté à des consultations assurées par un senior. 93,8% avaient participé à un staff de programmation opératoire. Sur un mois, la fréquence d'assistance au bloc opératoire comme premier aide opératoire avait une médiane de 4 (1­10). Une personne sur 15 a bénéficié régulièrement de débriefing après la réalisation d'un acte de soins. La durée de travail quotidien hospitalier était comprise entre 4h et 8h pour 68,9% des résidents. CONCLUSION: L'avis des médecins en formation sur les compétences urologiques souligne la nécessité de soutenir le développement du DES d'urologie et d'andrologie à Cotonou.

[Learning ultrasonography: where do the anesthesiology residents of the French north-eastern sector currently stand?]. / Enquête sur l'apprentissage de l'échographie par les internes d'anesthésie-réanimation de l'inter-région Est.

OBJECTIVE: Ultrasonography is in continuing expansion in anesthesiology and critical care medicine (ACCM). It is an operator-dependent tool whose contribution is partly related to the quality of the user's initial and subsequent training. Within the framework of the ACCM residency, the French north-east anesthesiology residents have an initiation to ultrasonography by 24 hours of formal lectures. The evaluation of this teaching has not yet been performed. The objective of this survey is to depict this learning and delineate the expectations of the residents. METHODS: An anonymous computerized self-rated survey, published on a specific internet website, was performed between September 2011 and January 2012, and addressed to the ACCM residents of the French north-east anesthesiology residency by the local coordinators. It consisted in several items: current abilities and aims in echography, equipment availability and frequency of use, existence of a potential independent ultrasonography training, desired improvements, evaluation of the teaching and interest of rendering it mandatory, potential interest in creating a form of assessment. RESULTS: In total, 105 questionnaires were analyzed (response rate 44%). The distribution of respondents was homogeneous from the 1st to the 5th year of residency. Thirty percent of residents had good knowledge or mastered echocardiography. Ultrasound-guiding during vascular access was the best acquired technique: 73% masterized or had good knowledge of it. The results were more mitigated regarding ultrasound-guided regional anesthesia (UGRA) (60%), trans-cranial echography (46%), FAST-echo (23%), pleuro-pulmonary echography (38%). At the end of the ACCM residency, 69% wished to master echocardiography and 86% UGRA. The echograph was used more than once a week (76%) and of easy access (93%). The teaching was mainly theoretical; 76% of the residents were unsatisfied and nine out of ten had followed an echography training outside the ACCM residency courses or intended to do so. Moreover, 78% wished a mandatory echography learning, with seminars and a strengthened practical training: 94% considered workshops indispensable, and 62% simulation sessions. An assessment of knowledge was found useful, particularly in practical form. The realization of a training rotation with echographic orientation was desired by 78% of respondents. CONCLUSION: A clear gap exists between the real capability in echocardiography and the intended one. UGRA and echocardiography raise a particular interest. The practical training in ultrasonography using simulation and workshops is to be favored.

[Severe facial trauma: control of the upper airway?]. / Traumatisme facial: quelle prise en charge des voies aériennes supérieures ?

This is the case report of a 16-year-old male who suffered major facial trauma in a road traffic accident (unhelmeted scooter rider against signpost). During prehospital care, he was stable and awake. He was admitted to the emergency room of our university hospital and rapidly transferred, in a sitting position and breathing spontaneously, to the operating room for emergent surgical tracheostomy under local anaesthesia and sedation. This procedure turned out to be difficult (sitting position, patient uncooperative) and ventilatory compromise led us to intubate the patient without difficulties: indeed, supraphysiological mouth aperture (due to multifocal mandible fractures) and presence of supraglottic bubbling under spontaneous ventilation facilitated intubation in spite of major oropharyngeal bleeding. This allowed rapid restoration of adequate ventilation and tracheostomy was performed under standard conditions without further problems. This case report confirms the superiority of orotracheal intubation under light sedation over emergent tracheostomy in this type of situation, as stated under the SFAR guidelines.

[Efficiency and safety of recombinant activated factor VII in a case of severe postpartum hemorrhage]. / Efficacité et tolérance du facteur VIIa recombinant dans l'hémorragie grave du post-partum: à propos d'un cas et revue de la littérature.

We report the case of a severe postpartum hemorrhage (PPH) that was successfully treated with two administrations of recombinant activated factor VII (rFVIIa). Two major thromboembolic events (TEE) occurred shortly afterwards: the first was an acute lower limb ischemia at H3, the second was a cardiac arrest complicating a massive pulmonary embolism on day 5. Fortunately, both events had a favorable outcome. This case report allows us to discuss the role of rFVIIa during severe PPH and its potential responsibility in these two major TEE.

[Eclampsia]. / Eclampsie.

Eclampsia, the major neurological complication of preeclampsia, is defined as a convulsive episode, or any other sign of an altered consciousness, arising in a setting of preeclampsia, and which cannot be attributed to any other preexisting neurological condition. Convulsive episodes have been described up to 15 days post-partum. Visual disturbances (cortical blindness) are common and must be considered as the equivalent of a convulsive crisis. In case of doubt, the gold standard investigation is the performing of a diffusion weighted MRI. The management of women suffering a convulsive episode is the same as in any other generalized tonic-clonic seizure. Magnesium sulfate as a loading dose followed by a continuous infusion is the most effective way for preventing a relapse associated with blood-pressure normalization. Magnesium sulfate infusion must be maintained for 24 hours following the last convulsive episode.

Continuous at-home postoperative analgesia using a catheter in the case of hand surgery: preliminary study about 40 cases.

In hand surgery, ever since continuous at-home postoperative analgesia (CPA) was implemented, procedures which cause pain for more than 24h can now be performed in ambulatory surgery. The aim of our work was to study the feasibility of CPA. Our series comprised 40 patients with a mean age of 50 years. Twenty-four patients had an ASA score of 1 and 16 patients had an ASA score of 2. Indications were osteoarthritis and rheumatoid diseases. Three steps were involved: preoperative (patient screening and information), peroperative (placement of a peripheral nerve catheter through an axillary approach using an elastomeric device) and postoperative (at-home patient care provided by visiting nurses). Evaluation was rated using a CPA score (0 to 10) based on analgesia quality and network organization data. The global CPA score was 1.85. The quality of analgesia (2.6) scored less than the quality of organization (1.1). In the case of analgesia, sleep obtained the lowest score, followed by pain, and lastly, unwanted events. As far as organization was concerned, the network obtained the lowest score, followed by patient satisfaction, and lastly, patient information. Problems were encountered due to insufficient nurse training, analgesia failures, as well as unwanted events related to the oral antalgic treatment. However, technical success was almost always achieved. Our results show that the indications for ambulatory surgery could be extended and hospital-private practice networks be further developed. CPA appears to be a promising technique for analgesia and ambulatory surgery.

[Assessment of quality in day-case hand surgery]. / Démarche d'assurance qualité en chirurgie ambulatoire de la main.

OBJECTIVE: To determine the level of satisfaction in terms of pain relief and comfort among patients receiving different postoperative analgesia protocols after hand surgery under regional anaesthesia in a day care unit. METHODS: Cohort study among patients after hand surgery under regional anaesthesia during two consecutive three months time periods, with patient stratification according to the expected pain level with different balanced analgesia protocols (group A: carpal tunnel, group B: other surgery without bone involvement, group C: bone surgery). A telephone survey, scoring analgesia and comfort, each with a numerical (0-10) scale was conducted on days 1 and 7. During the first period analgesia for groups A and B was the same (acetaminophen-dextropropoxyphene or acetaminophen-codeine) and group C patients were treated with acetaminophen-ketoprofen-tramadol. In the second period analgesia was reduced for group A (acetaminophen alone) and increased for group B (acetaminophen-ketoprofen-tramadol) and group C (duration increased from 3 to 7 days). RESULTS: For carpal tunnel surgery, analgesia with acetaminophen alone was efficient, (Pain scale [PS] d0=2[0-10], PS d1=1 [0-10] and PS d2-d4=0,5 [0-10]). This surgery does not elicit important pain, there is no benefit in adding other analgesics. For group B, a significant improvement in postoperative pain was observed (postoperative d1 p<0.03) with a major increase in side effects (2/57 vs 17/48 p<0.001). For group C, therapeutic changes were ineffective (PS d0=2 vs 3.5 et PS d1=3 vs 5 [NS]) and we noticed an increase in side effects (p<0.05). One third of all patients are totally satisfied on day 7, logistic regression showing the role of inefficient analgesia in late postoperative period (PS>2 between d2-d4). Between day 1 and day 7, 20% of the patients change their point of view, those who feel less satisfied on day 7 complained of a more severe postoperative pain between day 2 and 4 (p<0.001) and between day 5-7 (p<0.01). CONCLUSION: For hand surgery on day case, quality of late postoperative analgesia (day 2-day 7) is strongly related to patient's satisfaction on day 7.

[Assessment of patient satisfaction after regional anaesthesia in two institutions]. / Evaluation de la satisfaction des patients ayant bénéficié d'une anesthésie locorégionale par bloc nerveux périphérique: étude bicentrique sur 314 cas.

OBJECTIVES: This study was designed to assess patient satisfaction after regional anaesthesia for limb surgery. METHODS: An anaesthesia satisfaction questionnaire was developed, validated (Kappa coefficient) and submitted to 314 patients operated in two institutions (one university hospital with anaesthesiology residents and one specialised in orthopaedics with experienced anaesthesiologists). Items explored were information modalities, pain and anxiety during procedure and global satisfaction rated with four levels (very satisfied [VS], satisfied [S], partially satisfied [PS], non-satisfied [NS]). Patients were interviewed by telephone at postoperative D1 and D8 by a pharmacist student not involved in the patient's care. RESULTS: Inspite of a high level of patient satisfaction at D8 (VS: 50%, S: 44%), some interesting aspects should be emphasised: a) sedation given before nerve block was not efficient to reduce anxiety and pain during procedure; b) VS levels decreased from D1 (56%) to D8 (50%) mainly because of late postoperative pain (after discharge) and discomforts; c) willingness to undergo the same nerve block again (294/314) was not correlated with patient's satisfaction since among PS and NS patients, a majority (9/15) wished for a block in case of renewed limb surgery; d) multivariate analysis showed that VS level was highly correlated with the quality of communication by the anaesthesiologist mainly for informations about pre and postoperative periods. No correlation was found with pain level during procedure; e) satisfaction levels were not different in the two institutions. CONCLUSION: This study has emphasised some important factors of patient satisfaction which were not sufficiently taken into account in our daily practice.

[Role of MRI in the diagnostic of Gayet Wernicke's encephalopathy (GWE) after gastrectomy and parenteral nutrition]. / Apport de l'IRM dans le diagnostic de l'encéphalopathie de Gayet Wernicke (EGW): à propos d'un cas après gastrectomie et nutrition parentérale.

GWE is rarely described after gastric surgery following parenteral nutrition. The case of a 33 years old female with no previous alcohol addiction, who presented severe neurological disorders after reoperation for postoperative peritonitis and total parenteral nutrition is reported. She was operated 8 days before for gastric leiomyoma and underwent partial gastrectomy. The management has consisted of a tracheal intubation and welfare ventilation. The brain CT scan was normal and the brain MRI made the diagnostic of Gayet Wernicke's encephalopathy with typical signs. An inner, bilateral and symetrical on both sides of the 3rd ventricle, thalamic hypersignal. After treatment in ICU including mechanical ventilatory support and thiamine infusion, she recovered with minor neurological sequelae concicting in amnesia and false recognition. The control of MRI after 5 weeks returned to normal. Mandatory of thiamine to parenteral nutrition is recommended.

[Ringer solution: osmolarity and composition revisited]. / Le soluté de Ringer: un standard "isotonique" discutable.

The composition of Ringer solution, a crystalloid fluid that is often used in anaesthesia and intensive care, varies depending on the manufacturer. The knowledge of the actual content in electrolytes and of the characteristics of this fluid is necessary before it is used. We call attention to a certain Ringer solution (Ringer Maco Pharma, Maco Pharma), for which the manufacturer's information about the tonicity and the osmolarity was incorrect. Contrary to what is written on the bag and in the product description (isotonicity, osmolarity of 276.8 mOsm/l), the theoretical osmolarity was 221.4 mOsm/l and the measured osmolality was about 208 mmol/kg, exposing the hypotonic characteristics of this fluid. The use of this product is potentially dangerous in patients with pathologies where the infusion of free water is especially badly supported.

[Should we use catheter replacement with the aid of wire introducer?]. / Faut-il faire des changements de cathéters sur guide ?

Two types of catheter replacement with the help of wire introducer are reported: systematic scheduled replacement and replacement in case of suspicion of catheter related infection. Guidelines do not recommend systematic scheduled replacement of the catheters. In case of suspicion of catheter infection, French consensus guidelines allow the use of wire introducer in the absence of local risk and of signs of severity. The American guidelines do not recommend the catheter change over guidewire in this setting.

[Intra-abdominal pressure measurement using a bladder catheter]. / Mesure de la pression intra-abdominale par voie vésicale.

In case of abdomen compartment syndrome, measurement of bladder pressure is an accurate means to assess peritoneal pressure. Authors describe measurement technique and pitfalls to avoid.