Improving management of intravenous maintenance fluids in the emergency department of a university hospital.

OBJECTIVE: Intravenous (IV) fluid therapy is a known source of iatrogenic complications. Guideline implementation can be used to educate and guide physicians on adequate fluid management. In the emergency department (ED), a complex and interruption-driven environment, workload is high and active documentation is required to facilitate audits of fluid management quality. PATIENTS AND METHODS: Fluid management was evaluated in the ED records of adult non-critically ill patients admitted to a tertiary care center before (PRE: 1/12/2016-31/3/2017) and after (POST: 1/12/2018-31/3/2019) implementation of an educational intervention aiming to optimize IV fluid therapy in November 2018. First, the appropriateness of the 24-hour IV maintenance fluid prescription was evaluated, as prescribed by the emergency physician. Second, factors associated with appropriate prescribing were assessed, as well as the quality of fluid management documentation practice. Prescription appropriateness and documentation quality were evaluated retrospectively using a structured audit instrument and additional review by experts. RESULTS: A total of 237 patients (2.3%) were included in the PRE-intervention group and 253 patients (2.4%) in the POST-intervention group. The expert panel evaluated 214 prescriptions in 82.3% of patients (PRE: 99, POST: 115), and appropriateness increased significantly (19.2% vs. 61.2%, p=0.002). A higher odds of an appropriate IV maintenance fluid prescription was determined, attributed to the intervention (adjOR=2.580; 95% CI 1.363-4.884) and in patients having a prehospital intervention (adjOR=1.914, 95% CI 1.022-3.586). Appropriateness of fluid management documentation did not significantly improve after the implementation of the intervention (15.6% vs. 16.2%, p=0.858). CONCLUSIONS: The IV fluid prescriptions' appropriateness was significantly higher after guideline implementation. However, documentation quality of fluid management was poor in the studied ED records. Active stewardship programs are warranted to further monitor fluid management quality in the ED.

The evolution of ultrasound guided foam sclerotherapy.

UNLABELLED: To know the future one must look to the past. AIM: To review the history of sclerotherapy and the application of duplex ultrasound guided foam sclerotherapy (UFS) to the treatment of varicose veins. METHOD: The development of sclerotherapy in the treatment of varicose veins during the last century is described with the introduction of ultrasound guided foam sclerotherapy during the last decade. Foam sclerotherapy is described and the possible side effects are discussed. No long-term (10 years) random trial results are yet available. CONCLUSION: Ultrasound guided foam sclerotherapy is a useful technique in the management of chronic venous disease.

Capnography monitoring during neurosurgery: reliability in relation to various intraoperative positions.

UNLABELLED: In neurosurgery, estimation of PaCO2 from PETCO2 has been questioned. The aim of this study was to reevaluate the accuracy of PETCO2 in estimating PaCO2 during neurosurgical procedures lasting >3 h and to measure the effect of surgical positioning on arterial to end-tidal CO2 gradient (P[a-ET]CO2) over time. One hundred four neurosurgical patients classified into four groups (supine [SP], lateral [LT], prone [PR], sitting [ST]) were included in a prospective study. PaCO2, PETCO2, and P(a-ET)CO2 were measured after induction of anesthesia (T0), after positioning (T1), each following hour (T2, T3, T4), and at the end of the procedure after return to the SP position (T5). Data are expressed as the mean +/- SD, and statistical analysis used linear regression, the Bland-Altman method, and analysis of variance. The mean durations of positioning and surgery were 4.1+/-1 h and 3.7+/-1.3 h, respectively. We performed 624 simultaneous measurements of PaCO2 (33+/-5 mm Hg) and PETCO2 (27+/-4 mm Hg), leading to a mean P(a-ET)CO2 of 6+/-4 mm Hg. P(a-ET)CO2 of the LT group (7+/-3 mm Hg) was larger (compared with the SP, PR, and ST groups) because of a lower PETCO2 (26+/-4 mm Hg). Negative P(a-ET)CO2 (PETCO2 > PaCO2) occurred 22 times, only in the SP (n = 9) and ST groups (n = 13). Changes in opposite directions of PETCO2 and PaCO2 between two successive measurements were found in 26% of the cases. Correlation coefficients in the four groups (PaCO2 versus PETCO2) were not in good agreement (0.46 to 0.62; P < 0.001). The mean bias was between 5 and 7 mm Hg. The superior (13-15 mm Hg) and inferior (-5 to 0 mm Hg) limits of agreement were too large to expect PETCO2 to replace PaCO2. In conclusion, during neurosurgical procedures of >3 h, capnography should be performed with regular analysis of arterial blood gases for optimal ventilator adjustment. IMPLICATIONS: This study, which aimed to reevaluate the ability of PETCO2 to estimate PaCO2 during neurosurgical procedures according to surgical position, indicates that PETCO2 cannot replace PaCO2 for the following reasons: scattering of individual values; occurrence of negative arterial to end-tidal CO2 gradient (P[a-ET]CO2; PaCO2 and PETCO2 variations in opposite directions; large changes in P(a-ET)CO2 between two samples; and instability of P(a-ET)CO2 over time.

[Relation between insufficiency of the venae comitantes and varices]. / Le rapport entre l'insuffisance des veines jumelles et les varices.

The author explains the relationship between geminal veins insufficiency and varicose veins. Anatomy, physiology, etiology, diagnosis and treatment are described.

[Varicose recurrence in the popliteal fossa]. / Récidive dans le creux poplité.

The authors present a case of recurrent popliteal space varices. The phlebography, clinical signs and surgical technic are presented. The cause of the recurrence and ways of preventing it are described.

[Aneurysm of the popliteal vein]. / Aneurisma van de vena poplitea.

The authors present a saccular aneurysm of the popliteal vein. The clinical findings, the diagnosis and the operative treatment are described. The authors suggest a possible etiology for the genesis of the aneurysm. Literature is reviewed.

[Sigmoid necrosis: a complication of total hip replacement]. / Sigmoïd necrose: een complicatie van total hip replacement (THR).

After total hip replacement on the left side, a patient developed sigmoid necrosis, apparently as a major complication. Extensive review of the recent literature related to complications of total hip replacement.

[Study on a mock cerebro-spinal fluid (author's transl)]. / Etude d'un liquide céphalo-rachidien artificiel.

The work presented was initiated in order to evaluate the biological and clinical tolerance of the isotonic saline solution (9 p. mille) usually used in neuro-surgery directly in contact with the nervous tissue in comparison with a new solution proposed as a a mock cerebrospinal fluid. Clinically, two patient' populations including 75 patients each, were compared during dynamic investigation of intracranial pressure with intra-ventricular injections of different solutions. The effects of prolonged intra-ventricular perfusion with each solution were studied in animal models by: --electrophysiological analysis of EEG activity during perfusion --morphological observation: electronic microscopy of different cerebral structures after the perfusion. The biological tolerance was analyzed by the use of routine tissue culture of CNS tissue exposed to the two solutions. The results obtained show the toxicity of isotonic saline solution (9 p. mille) and the perfect tolerance of S.21.001 solution as a mock cerebro-spinal fluid.

[Vasogenic cerebral oedema. Changes in membrane ATPases. Correction by a phospholipid precursor (author's transl)]. / Oedème cérébral vasogénique. Altérations des ATPases membranaires. Restauration par un précurseur des phospholipides.

In vasogenic cerebral oedema, there is progressive quantitative and qualitative impairment of mitochondrial ATPase and of Na/K/ATPase. This impairment, which reflects the intracellular component of cerebral oedema, would appear to be related to changes in the phospholipid environment of the cell membrane enzymes. CDP choline, a metabolic phospholipid precursor, is to a certain extent capable of correcting this disturbed activity and at the same time reduce oedema.

[A rapid and simple method for the qualitative and quantitative determination of hexapropymate in biological fluids and organs (author's transl)]. / Une méthode simple et rapide pour la recherche et le dosage de l'hexapropymate dans les milieux biologiques et les organes.

The method is based mainly on the extraction of the substance by a small volume of organic solvent from an alkaline medium containing a fairly important amount of inorganic salt. The extract is then subjected to thin layer and/or gas chromatography. The authors present also the relative frequency that they met on hexapropymate intoxications together with the concentrations in blood obtained in cases accompanied with deep coma.