[For a more humane hospital: experience of medical mediators]. / Pour un hôpital encore plus humain: l'expérience de médecins médiateurs.

The legislation on patient's rights has considerably evolved during these last ten years. Its appropriation by users and its perception by care providers occur progressively. An important gap appears between the progresses of the medical sciences and techniques and the humane approach of the patient. The complaints remain relatively scarce compared to the number of treated patients. More frequent are the complaints linked to the care management, to the communication and humane relations. The hospital has to day with the CRUQ a permanent structure of relation with users. Medical mediation allows to listen to, explain, advise impartially patients and families. Its main goal is not to avoid litigation with the hospital but to improve the quality of care and the risk prevention. With this objective, it is necessary to develop a patient-centered care and to modify the behaviors toward a more humane relation.

Multicenter randomized comparison of the efficacy and safety of xenon and isoflurane in patients undergoing elective surgery.

BACKGROUND: All general anesthetics used are known to have a negative inotropic side effect. Since xenon does not have a negative inotropic effect, it could be an interesting future general anesthetic. The aim of this clinical multicenter trial was to test the hypothesis of whether recovery after xenon anesthesia is faster compared with an accepted, standardized anesthetic regimen and that it is as effective and safe. METHOD: A total of 224 patients in six centers were included in the protocol. They were randomly assigned to receive either xenon (60 +/- 5%) in oxygen or isoflurane (end-tidal concentration, 0.5%) combined with nitrous oxide (60 +/- 5%). Sufentanil (10 mcirog) was intravenously injected if indicated by defined criteria. Hemodynamic, respiratory, and recovery parameters, the amount of sufentanil, and side effects were assessed. RESULTS: The recovery parameters demonstrated a statistically significant faster recovery from xenon anesthesia when compared with isoflurane-nitrous oxide. The additional amount of sufentanil did not differ between both anesthesia regimens. Hemodynamics and respiratory parameters remained stable throughout administration of both anesthesia regimens, with advantages for the xenon group. Side effects occurred to the same extent with xenon in oxygen and isoflurane-nitrous oxide. CONCLUSION: This first randomized controlled multicenter trial on the use of xenon as an inhalational anesthetic confirms, in a large group of patients, that xenon in oxygen provides effective and safe anesthesia, with the advantage of a more rapid recovery when compared with anesthesia using isoflurane-nitrous oxide.

The evolution of human resource needs in Europe.

The distribution of anaesthesia-related staff in Europe is characterized by a wide disparity between countries--and also within countries, between the rural regions and between large and small cities. The density of anaesthesiologists varies in different European areas--for example, 4.4 per 100,000 inhabitants in Ireland compared to 15.6 in Italy; conversely, trainee anaesthesiologists are more numerous in those countries in which the number of qualified specialists is low. These large differences may be explained by factors such as the management of training and assessment, the existence (or otherwise) of nurses, and the workload; mainly in Eastern European countries, the factors include economic conditions and health care policies. Most important are (i) the regulation of entrants into the specialty, and (ii) the range of the anaesthesiologist's duties--including (as well as anaesthesia) intensive care, emergency medicine and pain management. Important modifications could come from an increase in the workload, a decrease in the working time, and perhaps from the development of migratory flows when Eastern European countries join the European Union. The evolution of anaesthesiology in the future will depend on many unknown events: progress in pharmacology and techniques, the development of day-case anaesthesia, the behaviour of new consumers and, above all, future health policies.

The cardiovascular effects of mivacurium in hypertensive patients.

UNLABELLED: Hypotension is common after mivacurium injection in healthy patients. This hemodynamic event had not been investigated in hypertensive patients characterized by more intense hemodynamic instability. In this open-label, multicenter, randomized, and controlled study, we sought to determine whether mean arterial blood pressure (MAP) and heart rate variations were larger in hypertensive versus normotensive patients after a bolus dose of mivacurium injected over 10 or 30 s. After the induction of anesthesia with fentanyl and etomidate, normotensive (n = 149) and hypertensive (n = 57) patients received a single dose of mivacurium 0.2 mg/kg injected over 10 or 30 s by random allocation. Heart rate and MAP were recorded electronically. The incidence of hypotension (defined as a 20% MAP decrease from the control value before mivacurium injection) was 21% and 36% (10-s injection) or 11% and 10% (30-s injection) in the Normotensive and Hypertensive groups, respectively. In Hypertensive patients, the maximum decrease in MAP was significantly greater when mivacurium was injected over 10 s compared with 30 s: 20% vs 11%, respectively (P = 0.002). This difference was not observed in Normotensive patients. Hypotension after rapid (e.g., 10 s) mivacurium injection was more frequent and more pronounced in Hypertensive than in Normotensive patients. IMPLICATIONS: When mivacurium (0.2 mg/kg) is injected rapidly (e.g., 10 s) the incidence and the intensity of hypotension are greater in hypertensive patients than in healthy patients.