Impact of a pilot team on patients' pain reduction and satisfaction in an emergency department: A before-and-after observational study.

BACKGROUND: Pain management and patient satisfaction were targeted in the emergency department of a Paris university hospital. In 1999, 77.0% of patients complained of pain on arrival and more than half of patients did not experience pain relief at discharge. The purpose of the study was to evaluate the outcomes of the implementation of a team piloting pain management on pain reduction and pain care satisfaction. METHOD: Two cross-sectional surveys (04/10/1999 to 19/10/1999 and 03/04/2007 to 18/04/2007) were conducted before and after a team piloting pain management was deployed in the emergency department. Consecutive patients age 18 years and older who visited the department suffering from pain were given structured questionnaires that validated scales scoring pain upon arrival and at discharge. Patients' files were analyzed using structured forms. The parameters associated with pain reduction and patient satisfaction were sought. RESULTS: In 2007, 65.0% of patients had their pain relieved vs. 35.1% in 1999 (P<0.001); 60.2% were satisfied with the pain care received vs. 39.8%. Pain management (e.g. waiting time ≤ 20 min: 47.6% vs. 20.8%; interventions on pain before the physician's examination: 63.0% vs. 13.8%; and pain reassessment after intervention: 13.8% vs. 4.5%) improved. Both pain reduction and patient satisfaction were significantly associated with intervention before the physician's examination. Pain reduction was independently and positively associated with time of survey, triage level (depending on the severity of their condition), pain intensity on arrival, and negatively associated with discharge without hospitalization. Satisfaction was independently and positively associated with waiting time before examination (0-20 min) and the absence of procedural pain. CONCLUSION: The implementation of a team piloting pain management seemed to have had positive effects on pain management in the emergency department. However, respectively, 56.2% and 39.8% of patients remained without pain relief and dissatisfied with pain management at the end of their visit.

Antibioprophylaxis in surgery and interventional medicine (adult patients). Update 2017.

Infection is a risk for any intervention. In surgery, for example, pathogenic bacteria are found in more than 90% of operative wounds during closure. This exists whatever the surgical technique and whatever the environment (the laminar flow does not entirely eliminate this risk). These bacteria are few in number but can proliferate. They find in the operative wound a favourable environment (haematoma, ischaemia, modification of oxido-reduction potential...) and the intervention induces anomalies of the immune defences. In the case of the installation of foreign material, the risk is increased. The objective of antibiotic prophylaxis (ABP) is to prevent bacterial growth in order to reduce the risk of infection at the site of the intervention. The preoperative consultation represents a privileged moment to decide on the prescription of a ABP. It is possible to define the type of intervention planned, the associated risk of infection (and therefore the necessity or not of ABP), the time of prescription before surgery and any allergic antecedents which may modify the choice of the selected antibiotic molecule.

[Prevalence and risk factors for substance abuse and dependence among anaesthetists: a national survey]. / Prévalence et facteurs de risque de l'addiction aux substances psychoactives en milieu anesthésique: résultats de l'enquête nationale.

OBJECTIVE: Addiction behaviours in the anaesthetist population have been recognized as a significant health-related issue and its scope is a matter of concern. METHODS: A national survey conducted among French anaesthetists consisted of a questionnaire designed to elicit information related to demographics, and work conditions, as well as substance consumption status. The study investigated the following: tobacco, alcohol, tranquillizers-hypnotics, and other agents such as cannabis, cocaine, opiates and anaesthetic agents. Respondents were classified in two categories: (no use and use)-(abuse and dependence). An univariate and multivariate analysis were performed to determine risk factors associated with drug abuse and dependence. RESULTS: 3,476 physicians responded to the questionnaire (38.0% response rate); 22.7% were daily tobacco smokers; 10.9% were abuser or dependent to one or more substances other than tobacco i.e. alcohol (59.0%), tranquillizers and hypnotics (41.0%), cannabis (6.3%), opiates (5.5%), and stimulants (1.9%). Sleep disturbances and negative perception of work environment were more frequently reported among addicted anaesthetists. CONCLUSION: In French anaesthetists, addiction is mainly related to alcohol consumption but includes a broad spectrum of substances. Addicted subjects report issues around work environment that may have contributed to the development of their pathology.

Effects of doxapram on hypercapnic response during weaning from mechanical ventilation in COPD patients.

Failure of weaning from mechanical ventilation in COPD patients is often related to diaphragmatic fatigue. Whether there is a central respiratory drive fatigue and a reserve of excitability is still debated. The purpose of this study was to analyze the following in 13 COPD patients weaned from mechanical ventilation: (1) ventilatory (VE/PETCO2) and neuromuscular (P0.1/PETCO2) response to hypercapnia; (2) the maximum reserve capacity measured through changes in the VE/PETCO2 and P0.1/PETCO2 slopes after doxapram (DXP) infusion, which, given during the test, allows measurement of the maximum response capacity to overstimulation; and (3) analyze the influence of these changes on the outcome of weaning. The results show a variable P0.1/PETCO2 response and a low VE/PETCO2. DXP infusion does not change the slopes of these relations but increases the end-expiratory volume (delta FRCd); (p less than 0.02). Since there was no change in the VE/PETCO2, P0.1/PETCO2, and delta FRC values with or without DXP, there was no excitability reserve in patients who were successfully weaned. When weaning failed, DXP did not change VE/PETCO2 and P0.1/PETCO2 slope, but delta FRCd was greater the delta FRC (p less than 0.001). The excitability reserve in these patients leads to an increase in end-expiratory volume, probably worsening the diaphragm dysfunction.

Diaphragmatic fatigue and breathing pattern during weaning from mechanical ventilation in COPD patients.

The medium-term outcome of weaning from mechanical ventilation in COPD patients is not easy to anticipate because a respiratory fatigue may eventually develop. We evaluated the diaphragmatic function and the breathing pattern during 40 weaning trials on 15 patients ventilated after acute respiratory failure. We formed two groups according to the success (group B, n = 18) or failure (group A, n = 19) of the medium-term attempt (group A/less than 10 hours; group B/more than 12 hours). Provided the patients showed the classic weaning criteria (tidal volume greater than 5 ml/kg, respiratory frequency less than 30 breaths per minute, PaO2 greater than 50 mm Hg), the study of the breathing pattern did not allow differentiation between the groups. However, the transdiaphragmatic pressure (Pdi) and the Pdimax, which gave an indication of the power of diaphragm contraction, dropped early in the group that could not stand weaning, with an increase in the Pdi/Pdimax ratio. In addition, this same group showed a diaphragmatic dysfunction attested for by a frequent negative gastric pressure associated with or shortly preceded by an abdominal paradoxic motion.

Steady-state breathing pattern responses to small inspiratory resistive loads in COPD patients. Application to weaning from mechanical ventilation.

We investigated the effect of small inspiratory resistive loads on the breathing patterns of patients with COPD admitted to the ICU for acute respiratory failure. Patients were in stable clinical condition three days after weaning from the acute-phase ventilation. Healthy nonsmokers served as controls. Breathing patterns were recorded for 20-min periods during unloaded breathing (R0), then with small inspiratory resistive loads (R1 = 2.5 cmH2O L/s and R2 = 5.2 cmH2O L/s) applied in random order. Respiratory parameters were memorized in real time and blood gases measured continuously with a transcutaneous PO2/PCO2 monitor and compared periodically with arterial blood gases. Minute volume (VE) and respiratory rate decreased with no modification in blood gas values. In the COPD patients, R1 was too small to be perceived; when R2 was applied, no increase in TI was observed, and VT and VT/TI decreased. The VE could not be maintained despite a shortening of expiratory time. The COPD patients did not have significant increase of occlusion pressure (P0.1). Mean blood gas values did not change during the testing, but the coefficient of variation of tcPCO2 increased. During the critical period following weaning from artificial ventilation, COPD patients did not respond in the same manner as normal subjects to inspiratory resistive loads, but did not have modified gas exchange during the 20-min period.

Acute respiratory distress syndrome due to falciparum malaria in a pregnant woman.

We report the case of a pregnant woman (29th week), living in a Paris suburb, about 20 miles from an international airport. She presented with septic shock and severe acute respiratory distress syndrome (ARDS). A few parasitized erythrocytes were discovered in a hemorrhagic bronchoalveolar lavage (BAL), specimen and many were found on examination of the placenta after a caesarean section had been performed. The patient's condition dramatically improved once given quinine therapy. This is an uncommon case on account of: (1) the unusual clinical course with no organ failure but ARDS, (2) the unusual way the diagnosis was made, (3) the very unusual way the patient became contaminated (airport malaria), (4) the pregnant condition of the patient.

Cost-effectiveness analysis of the terlipressin-glycerin trinitrate combination in the pre-hospital management of acute gastro-intestinal haemorrhage in cirrhotic patients.

OBJECTIVES: To assess the cost-effectiveness of an early treatment of upper gastro-intestinal haemorrages in cirrhotic patients. DESIGN: Utilization data linked to the results of a double-blind, placebo-controlled trial demonstrating the efficacy of the terlipressin-glycerin trinitrate combination (TER-GTN) in the reduction of mortality at day 42 for haemorragic patients due to rupture of oesophageal varices. SETTING: Hôpital Jean Verdier, Bondy, Assistance Publique-Hôpitaux de Paris, France. SUBJECTS: Eighty-four patients included over 2 years by emergency services and hospitalized in an intensive care unit (ICU) for haemorrage, 41 in the "treated" group and 43 in the "placebo" group. MAIN OUTCOME MEASURES: Mortality at day 42, cost per death avoided. RESULTS: The mortality rate in the placebo group was 46.5% versus 27.5% in the treated group. The mean length of stay was 5 days longer in the treatment group. The excess cost per death avoided was 25,849 FF. Of this extra cost 27% was due to treatment and 24% was due to increased length of stay. The excess cost per case treated was FF 5,097, 10% of the total cost per stay for rupture of oesophageal varices (ROV). CONCLUSIONS: Our results are of the same magnitude as those published by Mac Cormick et al. in the United Kingdom for similar treatment. The extra cost appears to be moderate, and much lower than monoclonal antibody therapy for sepsis. The impact on the study hospital budget did not exceed 1.7 10(-4).

Complication profiles of adult asthmatics requiring paralysis during mechanical ventilation.

OBJECTIVE: To assess the characteristics and the incidence of morbidity of intubated asthmatic patients who received long-term paralysis. DESIGN: Retrospective cohort study. SETTING: Five intensive care units (ICUs) in Paris and the surrounding suburbs. PATIENTS AND PARTICIPANTS: The NMB group consisted of patients who received neuromuscular blocking agents for more than 12 h (NMB group) versus sedation alone (SED). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The incidence of post-extubation muscle weakness and/or myopathy was 18% in the NMB group compared to 2% in the SED group ( p=0.01). The occurrence of ventilator-associated pneumonia was higher in the NMB group (42% versus 4%; p<0.0001). The duration of ICU stay and of mechanical ventilation were significantly greater in the NMB group. Multiple logistic regression analysis showed that inclusion in the NMB group was the only independent predictor of the presence of the overall morbidity [odds ratio 6.4 (2.09; 19.64)]. CONCLUSION: While greater initial severity of respiratory compromise in the NMB group may explain part of the difference, use of NMB agents appears to be strongly related to the presence of significant complications among mechanically-ventilated asthmatic patients.

Quality of perioperative antibiotic administration by French anaesthetists.

Antibiotics are the most prescribed drugs in hospitals in France and approximately one-third of prescriptions are for antimicrobial prophylaxis. Although the principles of prophylaxis have been defined over the years, there is still widespread misuse of antimicrobials for that purpose. The aim of this survey was to determine whether prescription of prophylactic antibiotics by French anaesthetists complies with the French Guidelines on Surgical Antibiotic Prophylaxis. Information was sought concerning the agent(s) recommended, the timing of the first dose and the duration of prescription. A total of 1473 French anaesthetists was studied. For the great majority (93%), the first antibiotic dose is administered at time of induction of anaesthesia, as recommended by the guidelines. First- and second-generation cephalosporins are frequently selected, as well as co-amoxiclav. In contrast to the guidelines, third-generation cephalosporins (3GCs) are widely prescribed in digestive and urological surgery and quinolones in urological surgery. Duration of prescription is limited to 48 h by most anaesthetists (94%), however there is a strong tendency to prescribe prophylaxis for longer periods in the immunocompromised and patients undergoing major surgery. This survey indicates discrepancies between the French Guidelines on Surgical Antibiotic Prophylaxis and the current practice of French anaesthetists. Major concerns are the use of antibiotics such as 3GCs or fluoroquinolones and prescription for periods exceeding 48 h. In conclusion, compliance with guidelines for prophylactic antimicrobial administration should be more strict in surgical patients.

Influence of acute renal failure on FPIA rapid serum assay of midazolam and its main metabolite.

We recently developed a simple and fast assay technique, providing the possibility of monitoring of midazolam (M) during sedation. We compared HPLC vs FPIA for the measurement of the sum M plus alpha 1-hydroxymidazolam (OM), its main and pharmacologically active metabolite, in the serum of sedated ICU patients; this activity referred to as M-like. We identified certain patients in whom M-like activity appeared abnormally high in comparison with HPLC assays. Their common denominators were: long-term sedation with M, and seriously impaired renal function. Further, the conjugates of OM (OMG) accumulated in patients with acute renal failure could contribute to the sedation. We compared the metabolic and analytic behavior of M, OM, and OMG in 2 groups of sedated patients either presenting with normal renal functions (group 1) or with a picture of acute renal failure (group 2). Blood samples were assayed by HPLC and by FPIA and analysis was performed before and after hydrolysis of OMG. Before hydrolysis there was a dramatic accumulation of OMG in the patients of group 2, HPLC vs FPIA results were not different within group 1, while in group 2 the FPIA response exceeded that of HPLC. After hydrolysis, measurement by HPLC was greatly increased in group 2, in each group (vs HPLC) and from one group to another, the FPIA signal (the M-like activity) showed a significant increase. It would be important to take OMG into account as a coprotagonist in sedation whenever circumstances predispose to its accumulation.

[Transient dysfibrinogenemia and thrombocytopenia associated with recurrent acute pancreatitis in the course of isotretinoin therapy]. / Dysfibrinogénémie et thrombocytopénie transitoires associées à une pancréatite aiguë récidivante lors d'un traitement par l'siotrétinoïne.

A 17 year-old young man developed two episodes of acute pancreatitis, separated by a 2 year interval and associated with isotretinoin therapy. In 1989, vesicular sludge without lithiasis was evidenced and in 1991, gall bladder stones were found by cholecystectomy. Concomitantly, transient dysfibrinogenemia and thrombopenia were present. It is interesting to note that far away from the use of isotretinoin, the patient suffered from another episode of acute pancreatitis without any coagulation disorder. The involvement of Roaccutane in cellular differentiation is discussed as well as its causal association with acquired dysfibrinogenemia and transient thrombocytopenia.

[Acute hemorrhagic pancreatitis]. / Pancréatite aiguë hémorragique.

Necrotizing acute pancreatitis is defined as necrosis of the adipose tissue, interstitial tissue and glandular tissue associated with areas of hemorrhage. Several causes are known predominantly biliary lithiasis and alcoholism. Severe consequences due to the release of pancreatic enzymes include activation of inflammation mediators which can lead to multiple organ failure. Although no therapy has been proven to be effective, progress in intensive care has helped reduce mortality. Rapid diagnosis and evaluation of the severity of illness with specific or general scores (Apache II score) are the keys to rapid management using therapies adapted to the degree of organ failure. Indication for surgery must be established in coordination with surgeons and depends both on the clinical course and computed tomography score.

[Perioperative antibiotic prophylaxis practice of French anesthesiologists and resuscitators: results of a national survey]. / Pratique de l'antibioprophylaxie périopératoire par les anesthésistes-réanimateurs français: résultat d'une enquête nationale.

Antibiotics are the most prescribed drugs in French hospitals in one third of cases they are used for antiobiotic prophylaxis in surgery. In spite of the guidelines for antibioprophylaxis produced in the last years, their prescription patterns remain still often inappropriate. This survey aimed to assess whether the prescription of antibiotics for prophylaxis by French anaesthetits complied with the French recommendations for antibioprophylaxis in surgery. It focused on the recommended agents, the time of the first injection, the duration of treatment. A sample of 1,473 anaesthetists participated in the survey. In 93% of cases, the first injection of the antibiotic took place at anaesthesia induction, as specified by the recommendations. Cephalosporins of the first and second generation were often administered, as well as the association amoxicillin-clavulanic acid. In contradiction with the recommendations, the cephalosporins of the third generation were widely prescribed in digestive and urological surgery, and the quinolones in urology and ophtalmology. The duration of treatment was restricted to 48 hours by 94% of anaesthetists. However there was a strong tendency to prolonge it in immunodepressed patients and in case of major surgery. This survey showed disparities between the French recommendations for antibioprophylaxis in surgery and the prescription patterns of anaesthetists. The lack of compliance occurred mainly for recent cephalosporins and treatment duration of over 48 hours. It is concluded that a stronger adherence to the principles of antibioprophylaxis is required in surgical patients.

[Immediate evaluation of continuous medical education]. / Evaluation pédagogique immédiate d'une action de formation médicale continue.

OBJECTIVES: To analyse the results of the immediate evaluation of an European teaching session using a questionnaire provided by the French College of anaesthesiologists. STUDY DESIGN: Open evaluation. MATERIAL: Questionnaires completed after each topic by 50 participants of an European course including 15 lectures were collected. METHODS: The types of professional exercise and the medical practise reliable to the different topics were pointed out. The evaluation included 4 items noted from 1 to 10: new information for medical practise, definition of pedagogic objectives, quality of means used for teaching, interest for the treated subject. The global mean score for each item and for each speaker was calculated. Results were compared according to the professional mode of exercise, the own medical practise and the project to modify it in the future. RESULTS: Scores affected to items were significantly lower for participants exercising in PSPH compared to general and university hospitals and private clinics (p < 0.001). New information was better found in case of poor or absence of practise, but interest was improved when medical practise was frequent. 2/3 of the participants projected to modify their practise after the session. CONCLUSION: The analysis of medical evaluation should allow to determine an acceptable zone of quality which may be useful for accreditation. However, distorting results according to the professional mode of exercise and the own medical practise should encourage the development of adapted continuous medical education. Delayed evaluation may be necessary to objective the putative benefits of CME on medical practise.

[Thromboembolic accidents in in vitro fertilization]. / Accidents thrombo-emboliques lors des fécondations in vitro.

The authors describe four thromboembolic accidents in vitro fertilisations. These accidents were not associated with an ovarian hyperstimulation syndrome. However, all patients presented a risk factor of thrombosis. The relationship between endocrine treatment and the occurrence of side effects is discussed.

[Amniotic embolism with favourable outcome]. / Embolie amniotique avec évolution favorable.

A 31-year-old multiparous pregnant woman forced into labour with oxytocin, suffered a sudden circulatory collapse and, after the birth of her child, a defibrination syndrome with uterine haemorrhage. In the absence of a local cause, either placental or cervico-uterine, a diagnosis of amniotic fluid embolism was made. The time course was favourable, mainly thanks to the absence of acute pulmonary cardiogenic oedema and to the use of an anti-shock G suit. The authors point out the lack of actual in vivo paraclinical means for confirming the diagnosis.

[Myocardial infarction in AIDS]. / Infarctus du myocarde et SIDA.

We report two cases of myocardial infarction, in young HIV positive patients seen in the Emergency Department. These patients were under treatments: for one, an association of nucleosidic inhibitors, and for the other one, the combination of nucleosic analogue inhibitor with a non nucleosic analogue; in the last case, the patient underwent, few months before, a treatment containing a protease inhibitor. In both cases, the pain wasn't typical and didn't refer to a coronary heart disease. Lipid tests were normal. The diagnosis has been made quickly and allows a coronary angioplasty with a favourable issue. Authors are arguing the characteristics of this cardiac pathology, recently discovered in HIV positive patients, and do insist on the need to think at a coronary heart disease in front of any chest pain symptom even unusual.

[Severity of illness explains the inadequacy between diagnosis-related groups and intensive care patients. Groupe GHM]. / La gravité de l'atteinte explique l'inadéquation entre le système des groupes homogènes de malades et les patients de réanimation. Groupe GHM.

OBJECTIVE: To assess the relationship between diagnosis related groups (DRG) and severity of illness in intensive care unit (ICU) patients in semf1tical and economical terms. STUDY DESIGN: Prospective, multicentric study including 13 medical and surgical ICUs for adults. MATERIAL: Discharge reports of 3,215 ICU admissions including age, gender, diagnosis, organ system failures, length of stay (LOS) and severity of illness evaluated with severity scores (SS): simplified acute physiological score (SAPS). Apache II, Glasgow score and physiological score (PS). METHODS: Semantical homogeneity was evaluated from the percentage of well-classified patients established from the comparison between the official computerized method and a non-computerized method applied by three clinical experts. Economical homogeneity was evaluated from the relationship between SS and LOS. RESULTS: In total, 88% (CI: 87.7-88.2) of ICU stays were classified in eight main categories of diagnosis (MCD). According to the MCD, the percentage of well-classified patients varied from 28% (CI: 27.6-28.3) to 97% (CI: 96.8-97.1), decreasing with the association of several diagnoses and organ system failures. There was a large variability in the LOS of DRG and a significant correlation between LOS and SS was found in only 8/16 DRG. CONCLUSION: The fact that the severity of illness is not taken into account in the elaboration of DRGs explains the inadequacy of the DRG system in intensive care.

[Meningitis after spinal anesthesia]. / Méningite après rachianesthésie.

The occurrence of meningitis after spinal anaesthesia is a very rare event. We report a case of Streptococcus sanguis meningitis following spinal anaesthesia for orthopaedic material removal. The presence of Gram positive cocci (Streptococcus sanguis) in the cerebrospinal fluid was in favour of an exogenous contamination, originating either from the patient's skin or the anaesthesiologist's oropharynx. The outcome was uneventful. The responsibility of the latter can result in legal consequences. The scrupulous compliance with guidelines prevents this risk.