One or two types of death? Attitudes of health professionals towards brain death and donation after circulatory death in three countries.

This study examined health professionals' (HPs) experience, beliefs and attitudes towards brain death (BD) and two types of donation after circulatory death (DCD)--controlled and uncontrolled DCD. Five hundred and eighty-seven HPs likely to be involved in the process of organ procurement were interviewed in 14 hospitals with transplant programs in France, Spain and the US. Three potential donation scenarios--BD, uncontrolled DCD and controlled DCD--were presented to study subjects during individual face-to-face interviews. Our study has two main findings: (1) In the context of organ procurement, HPs believe that BD is a more reliable standard for determining death than circulatory death, and (2) While the vast majority of HPs consider it morally acceptable to retrieve organs from brain-dead donors, retrieving organs from DCD patients is much more controversial. We offer the following possible explanations. DCD introduces new conditions that deviate from standard medical practice, allow procurement of organs when donors' loss of circulatory function could be reversed, and raises questions about "death" as a unified concept. Our results suggest that, for many HPs, these concerns seem related in part to the fact that a rigorous brain examination is neither clinically performed nor legally required in DCD. Their discomfort could also come from a belief that irreversible loss of circulatory function has not been adequately demonstrated. If DCD protocols are to achieve their full potential for increasing organ supply, the sources of HPs' discomfort must be further identified and addressed.

[Anaesthesic management of vaginal delivery in a parturient with C1 esterase deficiency]. / Prise en charge anesthésique d'un accouchement chez une patiente atteinte d'un déficit en inhibiteur de C1 estérase.

Hereditary and acquired angioedema (HAE/AAE) are the clinical translation of a qualitative or a quantitative deficit of C1 esterase inhibitor (C1 INH). The frequency and severity of clinical manifestations vary greatly, ranging from a moderate swelling of the extremities to obstruction of upper airway. Anaesthesiologists and intensivists must be prepared to manage acute manifestations of this disease in case of life-threatening laryngeal edema. Surgery, physical trauma and labour are classical triggers of the disease. The anaesthesiologists should be aware of the drugs used as prophylaxis and treatment of acute attacks when considering labour and caesarean section. Androgens are contraindicated during pregnancy. If prophylaxis is required, tranexamic acid may be used with caution. The safest obstetric approach appears to be to administer a predelivery infusion of C1 INH concentrate. It is important to avoid manipulation of the airway as much as possible by relying on regional techniques. We report the case of a patient suffering from an HAE discovered during pregnancy. The management included administration of C1 INH during labor and early epidural analgesia for pain relief. A short review of the pathophysiology and therapeutic options follows.

[Organization of an operational site. Comparison of the durations of intervention planned and real]. / Organisation d'un site opératoire. Comparaison des durées d'intervention prévues et réelles.

OBJECTIVE: To improve planning of our operational site by comparing the durations of intervention scheduled by the surgeons and the real durations of occupation of room of intervention, surgical procedure and surgical operation. STUDY DESIGN: Prospective study carried out of December 8, 2003 to February 27, 2004. PATIENTS AND METHODS: Anaesthetic and surgical times of the interventions of visceral and gynaecological surgery were raised. From these data several durations were calculated like the duration of occupation of the room of intervention, surgical procedure and surgical operation. These durations were compared with the durations envisaged by the surgeons to carry out the planning of the operational activity. RESULTS: Two hundred and ten interventions were studied. The analysis showed that there was a significant difference between the duration planned and the real duration of occupation of the room of intervention 45 minutes [5-125] (p<0.0001). The duration planned corresponded with duration of surgical operation, duration which did not take into account anaesthetic induction and surgical installation. CONCLUSIONS: The effectiveness of the planning of an operational site depends on the exactness of the durations scheduled, which are used for its realization. It is significant that all the actors of the operating theatre suite use the durations closest to reality.

Efficacy of augmentation of epidural analgesia for Caesarean section.

BACKGROUND: Extension of a labour epidural for Caesarean delivery is thought to be successful in most cases and avoids the use of general anaesthesia. However, most previous studies that have estimated the failure rate of pre-existing epidural catheters were performed in small numbers of patients. METHODS: Therefore, we undertook to retrospectively measure the failure rate of indwelling epidural catheters in a large number of patients. RESULTS: The anaesthetic team was available at all times and was permanently led by a senior anaesthetist specialized in obstetrics. Extension was performed using lidocaine 2% with epinephrine (mean 18 (SD 6) ml), combined in most patients with sufentanil (9 (2.2) microg) and/or clonidine (75 microg). Among 194 consecutive extensions performed in a 1-yr period, general anaesthesia was required in five patients (2.6%) while sedation and/or i.v. analgesia were used in 27 patients (13.9%). In three cases where general anaesthesia was required, the interval between decision to incision was <10 min. No factor associated with failure could be identified. Addition of a lipophilic opioid or of clonidine did not modify the efficacy of the block (i.e. general anaesthesia or supplementation were required in a similar proportion). CONCLUSIONS: The augmentation of labour epidurals for Caesarean section using lidocaine 2% plus epinephrine is a reliable and effective technique. No factor associated with failure could be identified.