[Failure to perform auto-test of anaesthesia machine at the opening of the operating room]. / Défaut de réalisation de l'autotest de la machine d'anesthésie à l'ouverture de la salle d'opération. Étude des pratiques.

BACKGROUND: controls performed at the opening of the operating room include the anesthesia machine auto-test. Omitting the preoperative checklist is unsafe for the patient and increases the risk of possible breakdowns. The purpose of this study was to evaluate the incidence and the situations in which the auto-test of the machine was not performed at the opening of the operative room. METHODS: from a database including 55 195 cases between 1st January 2002 and 31st July 2009, a query identified cases in which the auto-test of the anaesthesia machine was omitted and the cases in which anaesthesia was made in spite of the failure of this test. Clinical circumstances were analyzed and anaesthetist and/or nurse anaesthetist were identified from the computerized anaesthesia record. RESULTS: one hundred and ninety cases (1.24%) were identified. Seventy-three percent of the omissions of the auto-test occurred while on duty whereas 85% of the failures of the auto-test took place at the beginning of the scheduled program. Individual factor was identified since three anaesthesiologists out of 22 were responsible for 49% of omissions on duty and one nurse anesthetist was responsible for 18% of the use of a failed machine and 30% of the omission of the auto-test. CONCLUSION: the auto-test of the anesthesia machine was correctly made in most cases but there are still situations where the checklist wasn't carried out. Therefore, the human factor seems important and justifies to be taken into account.

[Survey and budgetary impact of anaesthesia machines failures]. / Surveillance et impact budgétaire des pannes des appareils d'anesthésie.

OBJECTIVE: To assess the incidence and the causes of failures of anaesthesia machines in relation to aging. Study design. - Prospective survey from january 1996 to july 2000. MATERIAL AND METHODS: The causes (mechanical or electronic), the moment of identification (checklist, maintenance operation or quality-control operation) of each anaesthetic machine failure, the repair cost and the maintenance cost of 14 anaesthetic machines have been collected and entered into a database. RESULTS: Over 31,948 anaesthesia delivered during the period of the study, 614 failures have been declared: 53% were related both to mechanical problems or monitoring failure and 40% were identified during the pre-operative checklist. In half of the cases, a specially trained anaesthetic nurse was able to correct the failure in the operating theatre. The annual rate of anaesthetic machine failure remained stable over the study period and the annual maintenance cost is approximatively 10% of the initial machine value. No procedure was cancelled because of a machine technical failure. CONCLUSION: Anaesthetic machine failure rate change according to the time should not be criteria for remplacement if rigorous quality control and maintenance operation are used.

Research on the best chemohyperthermia technique of treatment of peritoneal carcinomatosis after complete resection.

BACKGROUND: The complete or almost complete resection of peritoneal carcinomatosis (PC) followed by intraperitoneal chemohyperthermia (IPCH) is potentially capable of curing some patients presenting with disease confined to the peritoneum. AIMS: The aim of this prospective phase I-II study was to develop an efficient IPCH procedure with good thermal homogeneity and good spatial diffusion, that would be reproducible (and thus could be standardized and exported), and to evaluate patient tolerance and its efficiency in eradicating tumor tissue. METHODS: Seven IPCH procedures were tested successively in 32 patients (up to a total of 35 IPCH). Each procedure was tested in at least 4 patients before modifications for technical reasons or due to inacceptable tolerance. Five of them were followed by early postoperative intraperitoneal chemotherapy (EPIC) lasting 4 days. Thermal homogeneity was measured with 6 thermal probes placed in different positions inside the abdominal cavity. Spatial diffusion was studied in the last patients by adding methylene blue to the IPCH liquid. The mean follow-up was 23.85 months for the series. RESULTS: From the technological point of view, we have progressively shown that procedures with closure of the abdomen are not satisfactory: it was impossible to obtain thermal homogeneity when the entire parietal wound was closed, but markedly improved when only the skin was closed. However, these "closed" procedures did not allow us to treat all surfaces at risk. The peritoneal cavity "expander" did not permit treatment of the parietal wound and an indeterminate amount of the perfusion oozed out at its periphery. The open technique with traction of the skin upwards was superior. Using different procedures successively undermined the quality of the postoperative results. Three patients (8.6%) died and morbidity (albeit minimal) occurred in 27 patients (77%) during the postoperative course. Mortality and morbidity were significantly correlated (P = 0.02) with the peritoneal index (scoring the extent of PC). The 2-year survival rate was 60% and PC did not recur in 49% of the patients. The survival rate was correlated with the extent of PC (peritoneal index greater than or below 15) (P = 0.004), and with the absence of extraperitoneal disease (P = 0.01).

[Treatment of peritoneal carcinomatosis using complete excision and intraperitoneal chemohyperthermia. A phase I-II study defining the best technical procedures]. / Traitement des carcinoses péritonéales par exérèse complète et chimiohyperthermie intrapéritonéale. Etude de phase I-II permettant de définir la meilleure procédure technique.

OBJECTIVES: The complete or quasi complete resection of peritoneal carcinomatosis (PC) followed with IPCH is potentially able to cure some patients with a disease confined to the peritoneum. The aim of this prospective phase I-II study was to elaborate an efficient IPCH procedure with a good thermal homogeneity and a good spatial diffusion, which should be reproductible (and so standardizable and exportable), and to appreciate its tolerance and its carcinologic impact. PATIENTS AND METHODS: Seven IPCH procedures were successively tested in 32 patients (for a total of 35 IPCH); each of these were tested in at least four patients before being modified for technical or tolerance reason. Five of them were followed with an immediate postoperative intraperitoneal chemotherapy (IPIC) lasting four days. Thermal homogeneity was measured with six thermal probes situated in different places inside the abdominal cavity. Spatial diffusion was studied in the last patients by adding methylene blue in the IPCH liquid. The precise extent of the PC was reported, for each intra-abdominal region, and scored with a peritoneal index (ranging from 1 to 39). The mean follow-up was 23.85 months for the series. RESULTS: Procedures with the closure of the abdomen were not efficient: thermal homogeneity was almost satisfactory when only the skin was closed, but these 'closed' procedures did not permit the treatment of all the risky surfaces. The peritoneal cavity 'expander' did not permit the treatment of the parietal wound, and an undetermined amount of the perfusion oozed out at its periphery. The open technique by tracking the skin upwards was the best one. Death occurred in three patients (9.4%), and complications occurred in 24 patients (75%) during the postoperative course. Intra-abdominal complications were significantly correlated (P = 0.02) with the peritoneal index (scoring the extent of the PC). The two year survival rate was 60%, and PC did not recur in 50% of the patients. CONCLUSION: An efficient and reproducible procedure for IPCH was defined: an open procedure with an upwards traction of the skin. The post-IPCH IPIC was abandoned because it did not treat all the risky peritoneal surfaces. Patients with an extended PC and with extraperitoneal localization did not seem to have benefited from this therapeutic approach. Progress is needed in the chemotherapeutical procedure and indications must be more finely defined.

[The breakdown of anesthesia equipment survey]. / Enquête sur les pannes des appareils d'anesthésie.

OBJECTIVE: To assess the incidence and the causes of failures of anaesthesia machines. STUDY DESIGN: Prospective survey from August 1995 to September 1997. MATERIAL: Check-list and machine failure forms. METHODS: Failures of anaesthetic machines have been collected and entered into a database. Causes and treatment of each failure have been analysed. RESULTS: Of 5,096 foreseen forms, 3,926 (77%) have been completed after check-list or anaesthesia machine failure. Overall, 233 incidents have been declared (4.5%). Failures identified during the preoperative check-list (n = 96) were mainly related to mechanical problems, especially the gas proportioning device (35%). Perioperative failures (n = 137) were mostly related to electronic problems (ventilator: 27% and monitor: 57%). In more than half of the cases, a specially trained anaesthetic nurse was able to correct the failure in the operating theatre. Using 14 anaesthetic machines for 12 operating rooms, no procedure was cancelled because of a technical failure of a machine. CONCLUSIONS: This study emphasizes the value of the check-list and the failure report. The presence of a specially trained anaesthetic nurse allows immediate correction of the majority of technical problems.

[Pressure control in medical gas distribution systems]. / Contrôle des pressions dans les systèmes de distribution de gaz médicaux.

OBJECTIVE: To assess whether the pressure gauges at the downstream part of pressure regulators are accurate enough to ensure that pressure in O2 pipeline is always higher than in Air pipeline and that pressure in the latter is higher than pressure in N2O pipeline. A pressure difference of at least 0.4 bar between two medical gas supply systems is recommended to avoid the reflow of either N2O or Air into the O2 pipeline, through a faulty mixer or proportioning device. STUDY DESIGN: Prospective technical comparative study. MATERIAL AND METHODS: Readings of 32 Bourdon gauges were compared with data obtained with a calibrated reference transducer. Two sets of measurements were performed at a one month interval. RESULTS: Pressure differences between Bourdon gauges and reference transducer were 8% (0.28 bar) in average for a theoretical maximal error less than 2.5%. During the first set of measurements, Air pressure was higher than O2 pressure in one place and N2O pressure higher than Air pressure in another. After an increase in the O2 pipeline pressure and careful setting of pressure regulators, this problem was not observed at the second set of measurements. DISCUSSION: Actual accuracy of Bourdon gauges was not convenient enough to ensure that O2 pressure was always above Air pressure. Regular controls of these pressure gauges are therefore essential. Replacement of the faulty Bourdon gauges by more accurate transducers should be considered. As an alternative, the increase in pressure difference between O2 and Air pipelines to at least 0.6 bar is recommended.

[Quality control of anesthesia equipment after maintenance procedure]. / Contrôle-qualité des appareils d'anesthésie après opération de maintenance.

OBJECTIVE: To assess the value of quality control tests after routine maintenance procedures of anaesthesia machines. STUDY DESIGN: Prospective laboratory study. MATERIAL AND METHODS: Over a 4-year-period, anaesthesia machines were checked after regular maintenance procedures, in order to detect unrecognized dysfunctions before clinical use. RESULTS: Overall 106 tests were performed on 14 machines and five dysfunctions were identified. Three of them concerned gas proportioning devices, which delivered a hypoxic gas mixture (FO2 < 15%). This defect was recognized by gas analysis at their outlet, whereas mechanical controls were satisfactory. The last two concerned pressure relief valve linearity and gas leak at PEEP valve. CONCLUSIONS: This study underlines the necessity of both postmaintenance controls and gas analysis at the outlet of the gas proportioning device. These controls should be performed by hospital technicians, independent from those involved in regular maintenance procedures.