RESUMO
Surgical procedures involving the use of x-rays in the operating room (OR) have increased in recent years, thereby increasing the exposure of OR staff to ionizing radiation. An individual dosimeter makes it possible to record the radiation exposure to which these personnel are exposed, but there is a lack of compliance in the wearing of these dosimeters for several practical reasons. This makes the dose results obtained unreliable. To try to improve the rate of dosimeter wearing in the OR, the Dosibadge project studied the association of the individual dosimeter with the hospital access badge, forming the Dosibadge. Through a study performed at the Tours University Hospital in eight different ORs for two consecutive periods of 3 months. The results show a significant increase in the systematic use of the dosimeter thanks to the Dosibadge, which improves the reliability of the doses obtained on the dosimeters and the monitoring of personnel. The increase is especially marked with clinicians. Following these results and the very positive feedback to this first single-centre study, we are then planning a second multicentre study to validate our proof of concept on different sites, with the three brands of individual dosimeters used in France i.e. dosimeters supplied by Dosilab; Landauer and IRSN.
Assuntos
Exposição Ocupacional , Salas Cirúrgicas , Doses de Radiação , Dosímetros de Radiação , Monitoramento de Radiação , Exposição Ocupacional/análise , Exposição Ocupacional/prevenção & controle , Humanos , Monitoramento de Radiação/métodos , Raios X , Proteção Radiológica , Exposição à Radiação/análise , Desenho de EquipamentoRESUMO
BACKGROUND: Patients with acute brain injury are at high risk of ventilator-associated pneumonia (VAP). The benefit of short-term antibiotic prophylaxis remains debated. We aimed to establish the effect of an early, single dose of the antibiotic ceftriaxone on the incidence of early VAP in patients with severe brain injury who required mechanical ventilation. METHODS: PROPHY-VAP was a multicentre, randomised, double-blind, placebo-controlled, assessor-masked, superiority trial conducted in nine intensive care units in eight French university hospitals. We randomly assigned comatose (Glasgow Coma Scale score [GCS] ≤12) adult patients (age ≥18 years) who required mechanical ventilation for at least 48 h after acute brain injury to receive intravenous ceftriaxone 2 g or placebo once within the 12 h following tracheal intubation. Participants did not receive selective oropharyngeal and digestive tract decontamination. The primary outcome was the proportion of patients developing early VAP from the 2nd to the 7th day of mechanical ventilation, confirmed by masked assessors. The analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew or did not give consent to continue and those who did not receive the allocated treatment because they met a criterion for non-eligibility. The trial is registered with ClinicalTrials.gov, NCT02265406. FINDINGS: From Oct 14, 2015, to May 27, 2020, 345 patients were randomly assigned (1:1) to receive ceftriaxone (n=171) or placebo (n=174); 330 received the allocated intervention and 319 were included in the analysis (162 in the ceftriaxone group and 157 in the placebo group). 166 (52%) participants in the analysis were men and 153 (48%) were women. 15 patients did not receive the allocated intervention after randomisation and 11 withdrew their consent. Adjudication confirmed 93 cases of VAP, including 74 early infections. The incidence of early VAP was lower in the ceftriaxone group than in the placebo group (23 [14%] vs 51 [32%]; hazard ratio 0·60 [95% CI 0·38-0·95], p=0·030), with no microbiological impact and no adverse effects attributable to ceftriaxone. INTERPRETATION: In patients with acute brain injury, a single ceftriaxone dose decreased the risk of early VAP. On the basis of our findings, we recommend that an early, single dose of ceftriaxone be included in all bundles for the prevention of VAP in patients with brain injury who require mechanical ventilation. FUNDING: French Ministry of Social Affairs and Health.
Assuntos
Antibacterianos , Ceftriaxona , Pneumonia Associada à Ventilação Mecânica , Respiração Artificial , Humanos , Ceftriaxona/administração & dosagem , Ceftriaxona/uso terapêutico , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Feminino , Masculino , Método Duplo-Cego , Pessoa de Meia-Idade , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Respiração Artificial/efeitos adversos , Adulto , Idoso , Antibioticoprofilaxia/métodos , Lesões Encefálicas/complicações , Lesões Encefálicas/prevenção & controle , França , Unidades de Terapia Intensiva , Intubação Intratraqueal/efeitos adversos , Resultado do TratamentoRESUMO
BACKGROUND: Pediatric magnetic resonance imaging (MRI) and computed tompgraphy (CT) require patient immobility and therefore often require sedation or general anesthesia of patients. Consensus on these procedures is lacking in France. OBJECTIVE: Thus, the aim of this study was to describe the current sedation practices for pediatric MRI and CT in France. MATERIAL AND METHODS: From January 2019 to December 2019, an online questionnaire was delivered by electronic mail to a representative radiologist in 60 pediatric radiology centers registered by the French-speaking pediatric and prenatal imaging society. Questions included protocols, drugs used, monitoring and side effects. RESULTS: Representatives of 40 of the 60 (67%) radiology centers responded to the survey. Among them, 31 performed sedation including 17 (55%) centers where radiologists performed sedation without anesthesiologists present during the procedure. The premedication drugs were hydroxyzine (n = 8, 80%) and melatonin (n = 2, 20%), Sedation drugs used for children ages 0 to 6 years old were pentobarbital (n = 9, 60%), midazolam (n = 2, 13%), chloral hydrate (n = 2, 13%), diazepam (n = 1, 6.5%) and chlorpromazine (n = 1, 6.5%). A written sedation protocol was available in 10/17 (59%) centers. In 6/17 (35%) centers, no monitoring was used during the procedures. Blood pressure monitoring and capnography were rarely used (< 10%) and post-sedation monitoring was heterogeneous. No life-threatening adverse effect was reported, but 6 centers reported at least one incident per year. CONCLUSION: For half of the responding radiology centers, radiologists performed sedation alone in agreement with the local anesthesiology team. Sedation procedures and monitoring were heterogenous among centers. Adjustment and harmonization of the practices according to the capacity of each center may be useful.
Assuntos
Hidrato de Cloral , Hipnóticos e Sedativos , Criança , Humanos , Recém-Nascido , Lactente , Pré-Escolar , Hidrato de Cloral/efeitos adversos , Imageamento por Ressonância Magnética , Tomografia Computadorizada por Raios X , Inquéritos e Questionários , Sedação Consciente/efeitos adversos , Espectroscopia de Ressonância MagnéticaRESUMO
BACKGROUND: It is speculated that the anesthetic strategy during endovascular therapy for stroke may have an impact on the outcome of the patients. The authors hypothesized that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anesthesia. METHODS: In this single-blind, randomized trial, patients received either a standardized general anesthesia or a standardized conscious sedation. Blood pressure control was also standardized in both groups. The primary outcome measure was a modified Rankin score less than or equal to 2 (0 = no symptoms; 5 = severe disability) assessed 3 months after treatment. The main secondary outcomes were complications, mortality, reperfusion results, and National Institutes of Health Stroke Scores at days 1 and 7. RESULTS: Of 351 randomized patients, 345 were included in the analysis. The primary outcome occurred in 129 of 341 (38%) of the patients: 63 (36%) in the conscious sedation group and 66 (40%) in the general anesthesia group (relative risk, 0.91 [95% CI, 0.69 to 1.19]; P = 0.474). Patients in the general anesthesia group experienced more intraoperative hypo- or hypertensive episodes, while the cumulative duration was not different (mean ± SD, 36 ± 31 vs. 39 ± 25 min; P = 0.079). The time from onset and from arrival to puncture were longer in the general anesthesia group (mean difference, 19 min [i.e., -00:19] [95% CI, -0:38 to 0] and mean difference, 9 min [95% CI, -0:18 to -0:01], respectively), while the time from onset to recanalization was similar in both groups. Recanalization was more often successful in the general anesthesia group (144 of 169 [85%] vs. 131 of 174 [75%]; P = 0.021). The incidence of symptomatic intracranial hemorrhage was similar in both groups. CONCLUSIONS: The functional outcomes 3 months after endovascular treatment for stroke were similar with general anesthesia and sedation. Our results, therefore, suggest that clinicians can use either approach.
Assuntos
Isquemia Encefálica , Procedimentos Endovasculares , Acidente Vascular Cerebral , Anestesia Geral/efeitos adversos , Pressão Sanguínea , Sedação Consciente/métodos , Procedimentos Endovasculares/efeitos adversos , Humanos , Método Simples-Cego , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Trombectomia/efeitos adversos , Trombectomia/métodos , Resultado do TratamentoRESUMO
In France, the program of controlled donation after circulatory death (cDCD) was established with routine use of in situ normothermic regional perfusion (NRP). There is currently no consensus on its optimal duration. The purpose was to assess the impact of NRP duration on liver graft function and biliary outcomes. One-hundred and fifty-six liver recipients from NRP-cDCD donors from six French centers between 2015 and 2019 were included. Primary endpoint was graft function assessed by early allograft dysfunction (EAD, according to Olthoff's criteria) and MEAF (model for early allograft function) score. Overall, three (1.9%) patients had primary non-function, 30 (19.2%) patients experienced EAD, and MEAF score was 7.3 (±1.7). Mean NRP duration was 179 (±43) min. There was no impact of NRP duration on EAD (170±44 min in patients with EAD vs. 181±42 min in patients without, P = .286). There was no significant association between NRP duration and MEAF score (P = .347). NRP duration did neither impact on overall biliary complications nor on non-anastomotic biliary strictures (overall rates of 16.7% and 3.9%, respectively). In conclusion, duration of NRP in cDCD donors does not seem to impact liver graft function and biliary outcomes after liver transplantation. A 1 to 4-h perfusion represents an optimal time window.
Assuntos
Transplante de Fígado , Morte , Sobrevivência de Enxerto , Humanos , Transplante de Fígado/métodos , Preservação de Órgãos/métodos , Perfusão/métodos , Estudos Retrospectivos , Doadores de TecidosRESUMO
BACKGROUND: Sedation/analgesia is a daily challenge faced by intensivists managing patients with brain injury (BI) in intensive care units (ICUs). The optimization of sedation in patients with BI presents particular challenges. A choice must be made between the potential benefit of a rapid clinical evaluation and the potential exacerbation of intracranial hypertension in patients with impaired cerebral compliance. In the ICU, a pragmatic approach to the use of sedation/analgesia, including the optimal titration, management of multiple drugs, and use of any type of brain monitor, is needed. Our research question was as follows: the aim of the study is to identify what is the current daily practice regarding sedation/analgesia in the management of patients with BI in the ICU in France? METHODS: This study was composed of two parts. The first part was a descriptive survey of sedation practices and characteristics in 30 French ICUs and 27 academic hospitals specializing in care for patients with BI. This first step validates ICU participation in data collection regarding sedation-analgesia practices. The second part was a 1-day prospective cross-sectional snapshot of all characteristics and prescriptions of patients with BI. RESULTS: On the study day, among the 246 patients with BI, 106 (43%) had a brain monitoring device and 74 patients (30%) were sedated. Thirty-nine of the sedated patients (53%) suffered from intracranial hypertension, 14 patients (19%) suffered from agitation and delirium, and 7 patients (9%) were sedated because of respiratory failure. Fourteen patients (19%) no longer had a formal indication for sedation. In 60% of the sedated patients, the sedatives were titrated by nurses based on sedation scales. The Richmond Agitation Sedation Scale was used in 80% of the patients, and the Behavioral Pain Scale was used in 92%. The common sedatives and opioids used were midazolam (58.1%), propofol (40.5%), and sufentanil (67.5%). The cerebral monitoring devices available in the participating ICUs were transcranial Doppler ultrasound (100%), intracranial and intraventricular pressure monitoring (93.3%), and brain tissue oxygenation (60%). Cerebral monitoring by one or more monitoring devices was performed in 62% of the sedated patients. This proportion increased to 74% in the subgroup of patients with intracranial hypertension, with multimodal cerebral monitoring in 43.6%. The doses of midazolam and sufentanil were lower in sedated patients managed based on a sedation/analgesia scale. CONCLUSIONS: Midazolam and sufentanil are frequently used, often in combination, in French ICUs instead of alternative drugs. In our study, cerebral monitoring was performed in more than 60% of the sedated patients, although that proportion is still insufficient. Future efforts should stress the use of multiple monitoring modes and adherence to the indications for sedation to improve care of patients with BI. Our study suggests that the use of sedation and analgesia scales by nurses involved in the management of patients with BI could decrease the dosages of midazolam and sufentanil administered. Updated guidelines are needed for the management of sedation/analgesia in patients with BI.
Assuntos
Analgesia , Lesões Encefálicas , Estudos Transversais , Humanos , Hipnóticos e Sedativos , Unidades de Terapia Intensiva , Dor , Estudos Prospectivos , Respiração ArtificialRESUMO
PURPOSE: Minimally invasive parathyroid surgery and hypnosis are both increasing in prevalence. The objective of this study was to evaluate the efficacy of hypnoanalgesia compared with sedation during primary hyperparathyroid surgery under local anaesthesia. METHODS: All patients who underwent primary hyperparathyroid surgery under local anaesthesia in our department between January 2013 and April 2018 were included retrospectively in two groups: patients operated under hypnoanalgesia (HYP group), and patients operated under sedation (LA group). The evaluation criteria were postoperative pain and analgesic consumption, amount of perioperative anti-emetics required, and length of hospital stay. RESULTS: Thirty-six patients were included, 19 in the HYP group and 17 in the LA group. Postoperative pain levels and analgesic consumption rates were lower in the HYP group (numeric scale = 0.5/10 vs. 2.7/10, p = 0.0001; 11% vs. 47%, p = 4.9 × 10-8). Intraoperative anti-emetics delivery was lower in the HYP group (5% vs. 35%, p = 2.9 × 10-7). The ambulatory care rate was higher in the HYP group (74% vs. 59%, p = 0.03). CONCLUSION: Local anaesthesia with hypnoanalgesia, compared with sedation during minimally invasive parathyroid surgery, improved early postoperative outcomes, making outpatient management more efficient.
Assuntos
Anestesia Local , Hipnose , Analgésicos , Humanos , Dor Pós-Operatória/prevenção & controle , Estudos RetrospectivosRESUMO
INTRODUCTION: Treatment of acute stroke has drastically changed in the last 10 years. Endovascular therapy is now the standard of care for patients with a stroke caused by a large vessel occlusion in the anterior circulation. The impact of the type of anaesthesia (general anaesthesia or conscious sedation) during endovascular therapy on the outcome of the patients is still a matter of debate. Previous studies are mostly retrospective and/or focused on the early postprocedure outcome and/or without blood pressure goals and/or single-centre small size studies. We therefore designed a multicentre study hypothesising that conscious sedation is associated with a better functional outcome 3 months after endovascular therapy for the treatment of stroke compared with general anaesthesia. METHODS/ANALYSIS: The General Anesthesia vs Sedation for Stroke (GASS) Trial is a randomised, parallel, single-blind, multicentre study of 350 patients undergoing endovascular therapy for the treatment of stroke. Patients will be randomly allocated to receive either a general anaesthesia or a conscious sedation. The primary outcome measure is the modified Rankin score assessed 3 months after the treatment. Data will be analysed on the intention-to-treat principle. ETHICS/DISSEMINATION: The GASS Trial has been approved by an independent ethics committee for all study centres. Participant recruitment begins in September 2016. Results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT02822144.
Assuntos
Anestesia Geral , Sedação Consciente , Procedimentos Endovasculares , Acidente Vascular Cerebral/cirurgia , Adulto , Procedimentos Endovasculares/métodos , Feminino , Humanos , Masculino , Método Simples-CegoRESUMO
BACKGROUND: In 2011, the company that produced thiopental in France and in the United States stopped its marketing. Because of limited evidences, the choice of the best induction agent for caesarean section remains controversial, especially in emergency. The objective of this study was to compare the effects of propofol versus thiopental on the Apgar score of the newborn. METHODS: Newborns delivered by elective or emergency caesarean section under general anaesthesia in a university hospital were included from January 2009 to December 2013. Two periods, according to the hypnotic drug used, were compared in this before-and-after comparative study: thiopental before May 2011 and propofol after. The primary outcome was to compare the proportion of newborns with a 5-minute Apgar Score < 7 between both groups. RESULTS: 367 newborns were enrolled, 178 in thiopental group and 189 in propofol group. Demographic and clinical characteristics were similar in both groups. The occurrence of a 5-minute Apgar Score less than 7 was not influenced by the use of propofol (OR 1.40 [CI 95% 0.90-2.20] P = 0.135). Blood gas analyses and admission's rate in neonatal intensive care unit were similar in both groups. CONCLUSIONS: Thiopental and propofol do not appear to present significant difference in term of outcome of the newborn after caesarean section. In this situation, propofol may probably be a reliable alternative to the supply reduction of thiopental imposed by forces. Prospective studies are required to confirm the safety of propofol, particularly in the long term.
Assuntos
Anestesia Geral/métodos , Anestesia Obstétrica/métodos , Índice de Apgar , Cesárea , Feto/efeitos dos fármacos , Propofol , Tiopental , Adulto , Anestesia Geral/efeitos adversos , Procedimentos Cirúrgicos Eletivos , Emergências , Feminino , França/epidemiologia , Hospitais Universitários/estatística & dados numéricos , Humanos , Recém-Nascido , Placenta/metabolismo , Gravidez , Resultado da Gravidez , Propofol/efeitos adversos , Propofol/farmacocinética , Estudos Prospectivos , Indução e Intubação de Sequência Rápida , Tiopental/efeitos adversos , Tiopental/farmacocinética , Tiopental/provisão & distribuição , Adulto JovemRESUMO
OBJECTIVE: To provide French guidelines about "Airway management during paediatric anaesthesia". DESIGN: A consensus committee of 17 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie-Réanimation, SFAR) and the Association of French speaking paediatric anaesthesiologists and intensivists (Association Des Anesthésistes Réanimateurs Pédiatriques d'Expression Francophone, ADARPEF) was convened. The entire process was conducted independently of any industry funding. The authors followed the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to assess the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Few recommendations were not graded. METHODS: The panel focused on 7 questions: 1) Supraglottic Airway devices 2) Cuffed endotracheal tubes 3) Videolaryngoscopes 4) Neuromuscular blocking agents 5) Rapid sequence induction 6) Airway device removal 7) Airway management in the child with recent or ongoing upper respiratory tract infection. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the redaction of the recommendations were then conducted according to the GRADE® methodology. RESULTS: The SFAR Guideline panel provides 17 statements on "airway management during paediatric anaesthesia". After two rounds of discussion and various amendments, a strong agreement was reached for 100% of the recommendations. Of these recommendations, 6 have a high level of evidence (Grade 1 ± ), 6 have a low level of evidence (Grade 2 ± ) and 5 are experts' opinions. No recommendation could be provided for 3 questions. CONCLUSIONS: Substantial agreement exists among experts regarding many strong recommendations for paediatric airway management.
Assuntos
Manuseio das Vias Aéreas/normas , Administração Tópica , Extubação/métodos , Manuseio das Vias Aéreas/métodos , Algoritmos , Criança , Pré-Escolar , Desenho de Equipamento , França , Humanos , Lactente , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Laringoscopia/instrumentação , Laringoscopia/métodos , Lidocaína/administração & dosagem , Fármacos Neuromusculares não Despolarizantes/administração & dosagem , Indução e Intubação de Sequência Rápida , Infecções Respiratórias , Gravação em Vídeo/instrumentação , Gravação em Vídeo/métodosAssuntos
Empiema Subdural/etiologia , Pré-Eclâmpsia/diagnóstico , Complicações Infecciosas na Gravidez/diagnóstico , Infecções Estreptocócicas/diagnóstico , Streptococcus pyogenes/isolamento & purificação , Adulto , Empiema Subdural/complicações , Empiema Subdural/diagnóstico por imagem , Empiema Subdural/patologia , Feminino , Cabeça/diagnóstico por imagem , Humanos , Imageamento por Ressonância Magnética , Pré-Eclâmpsia/patologia , Gravidez , Complicações Infecciosas na Gravidez/patologia , Infecções Estreptocócicas/complicações , Infecções Estreptocócicas/patologiaRESUMO
STUDY OBJECTIVE: We evaluated if the sitting or supine positions affect anxiety levels induced by the application of a facemask in children. DESIGN: Prospective, randomised study. SETTING: Paediatric hospital, operating room. PATIENTS: Two to twelve years old children, 1-3 ASA status, undergoing inhalation anaesthesia for elective surgery. INTERVENTION: Children were randomly assigned to a sitting or supine position. After monitoring equipment was established, inhalation was inducted by the application of the mask. MEASUREMENTS: Child anxiety was then assessed with the modified Yale Preoperative Anxiety Scale (mYPAS) before the application of the facemask and following mask application. MAIN RESULTS: Overall, 99 children in the sitting group and 103 in the supine group were analysed. The mYPAS score was not different in both groups before the application of facemask (40 [28-51] versus 40 [28-53]; P=0.99). It increased (P=0.005) to a similar extent in both groups following mask application without difference between groups (48 [38-60] versus 48 [35-63]; P=0.95). Side effects were not different between both groups. CONCLUSION: In children undergoing inhalation induction, sitting or supine positions did not modify anxiety induced by the application of a facemask, nor adverse effects; therefore, children should be allowed to choose their preferred position.