High Frequency Jet Ventilation or Mechanical Ventilation for Panendoscopy for Cervicofacial Cancer: A Retrospective Study.

Introduction-the upper airway panendoscopy, performed under general anesthesia, is mandatory for the diagnosis of cervicofacial cancer. It is a challenging procedure because the anesthesiologist and the surgeon have to share the airway space together. There is no consensus about the ventilation strategy to adopt. Transtracheal high frequency jet ventilation (HFJV) is the traditional method in our institution. However, the COVID-19 pandemic forced us to change our practices because HFJV is a high risk for viral dissemination. Tracheal intubation and mechanical ventilation were recommended for all patients. Our retrospective study compares the two ventilation strategies for panendoscopy: high frequency jet ventilation (HFJV) and mechanical ventilation with orotracheal intubation (MVOI). Methods-we reviewed all panendoscopies performed before the pandemic in January and February 2020 (HFJV) and during the pandemic in April and May 2020 (MVOI). Minor patients, patients with a tracheotomy before or after, were excluded. We performed a multivariate analysis adjusted on unbalanced parameters between the two groups to compare the risk of desaturation. Results-we included 182 patients: 81 patients in the HFJV group and 80 in the MVOI group. After adjustments based on BMI, tumor localization, history of cervicofacial cancer surgery, and use of muscle relaxants, the patients from the HFJV group showed significantly less desaturation than the intubation group (9.9% vs. 17.5%, ORa = 0.18, p = 0.047). Conclusion-HFJV limited the incidence of desaturation during upper airway panendoscopies in comparison to oral intubation.

Impact of extending prevention of postoperative nausea and vomiting for cancer surgical patients in the PACU: a before and after retrospective study

Abstract Backgrounds Procedures for Postoperative Nausea and Vomiting (PONV) prevention are mostly based on identification of the risk factors before administering antiemetic drugs. The purpose of this study was to evaluate the impact of the extended use of antiemetic on the PONV in the Postanesthetic Care Unit (PACU). Methods Two separate 4-year periods (2007-2010, P1, and (2015-2018, P2) were evaluated. During P1, the protocol consisted of dexamethasone and droperidol for patients with a locally adapted high PONV score, followed by ondansetron for rescue in the PACU. For Period 2, dexamethasone (8 mg) and ondansetron (4 mg) were administered in patients under general or regional anesthesia, or sedation longer than 30 minutes, while droperidol (1.25 mg) in rescue was injected in cases of PONV in the PACU. An Anesthesia Information Management System was used to evaluate the intensity score of PONV (1 to 5), putative compliance, sedation, and perioperative opioid consumption upon arrival in the PACU. Results A total of 27,602 patients were assessed in P1 and 36,100 in P2. The administration of dexamethasone and ondansetron increased several fold (p < 0.0001). The high PONV scores were more improved in P2 than in P1, with scores (3+4+5) for P1 vs. P2, p < 0.0001. Overall, 99.7% of the patients in P2 were asymptomatic at discharge. Morphine consumption decreased from 6.9±1.5 mg in P1 to 3.5 ± 1.5 mg in P2 (p < 0.0001). Discussion The extension of pharmacological prevention of PONV was associated with a decrease in the intensity of severe PONV. However, uncertainty regarding confounding factors should not be ignored. IRB nº 92012/33465

Continuous Ropivacaine Peroneal Nerve Infiltration for Fibula Free Flap in Cervicofacial Cancer Surgery: A Randomized Controlled Study.

Introduction: Pain after cervicofacial cancer surgery with free flap reconstruction is both underestimated and undertreated. There is a rational for regional anesthesia at the flap harvest site, but few studies describe it. We assessed the influence of common peroneal nerve infiltration on pain and opioid consumption in patients having oropharyngeal cancer surgery with fibular free flap mandibular reconstruction. Methods: After institutional review board (IRB) approval and written informed consent, fifty-six patients were randomly allocated to perineural catheter with ropivacaine infiltration (ROPI) or systemic analgesia (CONTROL). In the ROPI group, an epidural catheter was placed by the surgeon before closure, and ropivacaine 0.2% 15 mL, followed by 4 mL/h during 48 h, was administered. The primary outcomes were pain scores and morphine consumption during the 48 h postoperative period. We also measured ropivacaine concentration at the end of infusion. Finally, we retrospectively assessed long-term pain up to 10 years using electronic medical charts. Results: Perineural infiltration of ropivacaine significantly reduced pain scores at the harvest site only at day 1, and did not influence overall postoperative opioid consumption. Ropivacaine assay showed a potentially toxic concentration in 50% of patients. Chronic pain was detected at the harvest site in only one patient (ROPI group), and was located in the cervical area in the case of disease progression. Discussion: Although the catheter was visually positioned by the surgeon, continuous ropivacaine infiltration of the common peroneal nerve did not significantly reduce postoperative pain, but induced a blood concentration close to the toxic threshold at day 2. Further studies considering other infiltration locations or other dosing schemes should be tested in this context, both to improve efficacy and reduce potential toxicity.

Pain after Interventional Radiology in Oncology: A Case-Control Study from a 5-Year Cohort.

Background: Interventional radiology plays a major role in oncology both for curative and palliative treatment, but few reports address post-procedural pain. The purpose of this study was to quantify postoperative pain after interventional radiology procedures in oncology and to identify major pain-associated pre and intraoperative factors. Methods: From 2015 to 2019, all patients treated with interventional radiology were included retrospectively in a cohort study. Anesthetic protocols were standardized by the type of radiological procedure. Demographic data, preoperative treatments, analgesic agents, pain score levels, and morphine consumption from the post-anesthesia care unit (PACU) to hospital discharge were collected from databases. In an additional case-control study, patients reporting strong or intolerable pain in PACU were compared to those with no pain. Matching to control cases was based on the type of intervention, sex, and age. Results: From 4411 procedures, severe pain in PACU was more frequent in women (p < 0.04) and the youngest patients (p < 0.0001), after general anesthesia (p < 0.0001). Higher pain levels were associated with certain procedures, such as arterial embolization, limb cementoplasty, osteosynthesis, and abdominal tumor ablation, and when the intervention duration exceeded 160 min (p = 0.038). In the cohort study, high-dose remifentanil (≥0.055 µg/kg/min) was a risk factor for post-procedural high pain levels (p < 0.001). Intraoperative ketoprofen was associated with a decrease in high pain level incidence (p < 0.0001). Severe pain in PACU was a risk factor for severe pain in wards from day 0 until discharge. Conclusion: Severe pain depends on the type and duration of interventional radiology, type of anesthesia, and preoperative use of opiates. Limiting doses of remifentanil and injecting intraoperative analgesics, especially ketoprofen, may reduce the incidence of post-intervention severe pain.

Impact of extending prevention of postoperative nausea and vomiting for cancer surgical patients in the PACU: a before and after retrospective study.

BACKGROUNDS: Procedures for Postoperative Nausea and Vomiting (PONV) prevention are mostly based on identification of the risk factors before administering antiemetic drugs. The purpose of this study was to evaluate the impact of the extended use of antiemetic on the PONV in the Postanesthetic Care Unit (PACU). METHODS: Two separate 4-year periods (2007...2010, P1, and (2015...2018, P2) were evaluated. During P1, the protocol consisted of dexamethasone and droperidol for patients with a locally adapted high PONV score, followed by ondansetron for rescue in the PACU. For Period 2, dexamethasone (8 mg) and ondansetron (4 mg) were administered in patients under general or regional anesthesia, or sedation longer than 30 minutes, while droperidol (1.25 mg) in rescue was injected in cases of PONV in the PACU. An Anesthesia Information Management System was used to evaluate the intensity score of PONV (1 to 5), putative compliance, sedation, and perioperative opioid consumption upon arrival in the PACU. RESULTS: A total of 27,602 patients were assessed in P1 and 36,100 in P2. The administration of dexamethasone and ondansetron increased several fold (p < 0.0001). The high PONV scores were more improved in P2 than in P1, with scores (3+4+5) for P1 vs. P2, p < 0.0001. Overall, 99.7% of the patients in P2 were asymptomatic at discharge. Morphine consumption decreased from 6.9..1.5 mg in P1 to 3.5 .. 1.5 mg in P2 (p < 0.0001). DISCUSSION: The extension of pharmacological prevention of PONV was associated with a decrease in the intensity of severe PONV. However, uncertainty regarding confounding factors should not be ignored. IRB: n.. 92012/33465.

End-Tidal Carbon Dioxide Pressure Measurement after Prolonged Inspiratory Time Gives a Good Estimation of the Arterial Carbon Dioxide Pressure in Mechanically Ventilated Patients.

BACKGROUND: End-tidal carbon dioxide pressure (PetCO2) is unreliable for monitoring PaCO2 in several conditions because of the unpredictable value of the PaCO2-PetCO2 gradient. We hypothesised that increasing both the end-inspiratory pause and the expiratory time would reduce this gradient in patients ventilated for COVID-19 with Acute Respiratory Distress Syndrome and in patients anaesthetised for surgery. METHODS: On the occasion of an arterial blood gas sample, an extension in inspiratory pause was carried out either by recruitment manoeuvre or by extending the end-inspiratory pause to 10 s. The end-expired PCO2 was measured (expiratory time: 4 s) after this manoeuvre (PACO2) in comparison with the PetCO2 measured by the monitor. We analysed 67 Δ(a-et)CO2, Δ(a-A)CO2 pairs for 7 patients in the COVID group and for 27 patients in the anaesthesia group. Results are expressed as mean ± standard deviation. RESULTS: Prolongation of the inspiratory pause significantly reduced PaCO2-PetCO2 gradients from 11 ± 5.7 and 5.7 ± 3.4 mm Hg (p < 0.001) to PaCO2-PACO2 gradients of -1.2 ± 3.3 (p = 0.043) and -1.9 ± 3.3 mm Hg (p < 0.003) in the COVID and anaesthesia groups, respectively. In the COVID group, PACO2 showed the lowest dispersion (-7 to +6 mm Hg) and better correlation with PaCO2 (R2 = 0.92). The PACO2 had a sensitivity of 0.81 and a specificity of 0.93 for identifying hypercapnic patients (PaCO2 > 50 mm Hg). CONCLUSIONS: Measuring end-tidal PCO2 after prolonged inspiratory time reduced the PaCO2-PetCO2 gradient to the point of obtaining values close to PaCO2. This measure identified hypercapnic patients in both intensive care and during anaesthesia.

Incidence of Severe Hypothermia and Its Impact on Postoperative Surgical Complications and Time Delay to Adjunct Treatments in Breast Surgery Cancer Patients: A Case-Controlled Study.

INTRODUCTION: Unintended postoperative hypothermia frequently occurs upon arrival in the post anesthesia care unit (PACU). As part of our quality assurance program in anesthesia, we regularly monitor the incidence of this complication through our anesthesia information management system (AIMS). In this case-controlled retrospective study, our goal was to detect the incidence of unintended severe hypothermia in our breast surgery cancer patients, and subsequently to analyze the consequence of this complication in terms postoperative cutaneous infection, as well as its impact on further complementary treatment, such as radiotherapy and chemotherapy. METHODS: This study was a retrospective analysis conducted through our AIMS system from 2015 through 2019, with extraction criteria based on year, type of surgery (breast), and temperature upon arrival in PACU. A tympanic temperature of less than 36 °C was considered to indicate hypothermia. Severe hypothermia was considered for patients having a temperature lower than 35.2 °C (hypothermic) (n = 80), who were paired using a propensity score analysis with a control group (normothermic) (n = 80) of other breast cancer surgery patients. Extracted data included time of surgery, sex, age, ASA status, and type and duration of the intervention. RESULTS: The mean incidence of hypothermia was 21% from 2015 through 2019. The body mass index (BMI) was significantly lower in the hypothermia group before matching, 23.5 ± 4.1 vs. 26.4 ± 6.1 kg/m2 in normothermic patients (p < 0.05). The hypothermia group also had significantly fewer monitoring and active warming devices. No difference was noted for wound complications. Time to complementary chemotherapy and or radiotherapy did not differ between groups (52 ± 21 days in group hypothermia vs 49 ± 22 days in the control group). CONCLUSION: Severe intraoperative hypothermia remains an important quality assurance issue in our breast surgery cancer patients, but we could not detect any long-term effect of hypothermia.

Comparison of the Time to Extubation and Length of Stay in the PACU after Sugammadex and Neostigmine Use in Two Types of Surgery: A Monocentric Retrospective Analysis.

Sugammadex provides a rapid pharmacological reversal of aminosteroid, as well as fewer pulmonary complications, a better physiological recovery, and shorter stays in the postanesthetic recovery unit (PACU). This retrospective analysis of our Centricity anesthesia database in 2017-2019 assessed the efficiency of sugammadex in real-life situations in two groups of surgical cancer patients (breast and abdominal surgery) based on the extubation time, operating room exit time, and length of PACU stay. Overall, 382 anesthesia records (131 breast and 251 abdominal surgeries) were extracted for the pharmacological reversal of neuromuscular blockades by neostigmine or sugammadex. Sugammadex was used for reversal in 91 breast and 204 abdominal surgeries. Sugammadex use did not affect the extubation time, operating room exit time, or length of PACU stay. However, the time to reach a 90% train of four (TOF) recovery was significantly faster in sugammadex patients: 2 min (1.5-8) in breast surgery and 2 min (1.5-7) in abdominal surgery versus 10 (6-20) and 9 min (5-20), respectively, for neostigmine (p < 0.05). Most patients who were reversed with sugammadex (91%) reached a TOF ratio of at least 90%, while 54% of neostigmine patients had a 90% TOF ratio recorded (p < 0.05). Factors other than pharmacological reversal probably influence the extubation time, operating room exit time, or PACU stay; however, sugammadex reliably shortened the time so as to reach a 90% TOF ratio with a better level of reversal.

Guidelines on muscle relaxants and reversal in anaesthesia.

OBJECTIVES: To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS: The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS: The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION: Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

Comparison of the TOF-Scan™ acceleromyograph to TOF-Watch SX™: Influence of calibration.

INTRODUCTION: Quantitative neuromuscular monitoring is now widely recommended during anesthesia using neuromuscular blocking agents to prevent postoperative residual paralysis and its related complications. We compared the TOF-Watch SX™ accelerometer requiring initial calibration to the TOF-Scan™, a new accelerometer with a preset stimulation intensity of 50mA not necessitating calibration. STUDY DESIGN: This pilot, prospective, observational study included adults undergoing general anesthesia with endotracheal intubation and muscle relaxation, having both arms free during surgery. Accelerometers were set up randomly on each arm. Anesthesia was started with remifentanil and propofol before an intubation dose of atracurium or rocuronium. Train of four stimulation was performed every 15s. Differences between measures were tested using Student's t-test and agreement assessed by Bland and Altman analysis. RESULTS: Thirty-two patients were included. During onset, a mean bias of -26seconds with a limit of agreement from -172 to +119seconds was observed between TOF-Watch SX™ and TOF-Scan™ to obtain 0 response to TOF. During recovery, TOF-Scan™ showed a significantly later recovery from 1 response to T4/T1>10%, but a bias of 0minute and limits of agreement from -4 to +4minutes for T4/T1>90% (NS). CONCLUSION: These results suggest a poor agreement between the calibrated TOF-Watch SX™ and the fix intensity TOF-Scan™ for onset and early recovery of relaxation (i.e. deep neuromuscular blockade) but a good agreement for recovery to TOF 90%. Data are not interchangeable between the devices, but both can be useful to detect residual paralysis.

An anaesthesia information management system as a tool for a quality assurance program: 10years of experience.

INTRODUCTION: Anaesthesia Information Management Systems (AIMS) generate large amounts of data, which might be useful for quality assurance programs. This study was designed to highlight the multiple contributions of our AIMS system in extracting quality indicators over a period of 10years. METHODS: The study was conducted from 2002 to 2011. Two methods were used to extract anaesthesia indicators: the manual extraction of individual files for monitoring neuromuscular relaxation and structured query language (SQL) extraction for other indicators which were postoperative nausea and vomiting (PONV), pain, sedation scores, pain-related medications, scores and postoperative hypothermia. For each indicator, a program of information/meetings and adaptation/suggestions for operating room and PACU personnel was initiated to improve quality assurance, while data were extracted each year. RESULTS: The study included 77,573 patients. The mean overall completeness of data for the initial years ranged from 55 to 85% and was indicator-dependent, which then improved to 95% completeness for the last 5years. The incidence of neuromuscular monitoring was initially 67% and then increased to 95% (P<0.05). The rate of pharmacological reversal remained around 53% throughout the study. Regarding SQL data, an improvement of severe postoperative pain and PONV scores was observed throughout the study, while mild postoperative hypothermia remained a challenge, despite efforts for improvement. DISCUSSION: The AIMS system permitted the follow-up of certain indicators through manual sampling and many more via SQL extraction in a sustained and non-time-consuming way across years. However, it requires competent and especially dedicated resources to handle the database.

Training experts in difficult airway management: Evaluation of a continuous professional development program.

OBJECTIVE: The Formation de référents aux techniques d'intubation difficile (FRTID) is a French continuing medical education program on difficult airway management. Its objectives are to train experts in the task of training other physicians in their hospitals for better guideline compliance. Our aim was to describe the curriculum of the experts and to evaluate the program's efficacy via a prospective survey. METHODS: Each participant was asked to complete a questionnaire before (T0), immediately (T1), 6 (T6) and 12 (T12) months after the course. The main criterion was the proportion of the participants who declared that they had implemented at least one action to improve difficult airway management in their institution at 6 months. Other criteria included the proportion of participants who declared that they had modified their own clinical practice and the frequency of use of specific devices assessed on modified Likert numerical rating scales. RESULTS: Two hundred and forty-four participants were included in the survey. One hundred and three, 91 and 62 participants responded to the T1 (immediately after the course), T6 (6 months later) and T12 (12 months later) questionnaires, respectively; 73 physicians (i.e. 30% of all participants and 80% of the survey responders) declared that they had implemented at least one action likely to optimize the management of difficult airways. On the T6 and T12 questionnaires, 91% and 97% of the responders respectively declared that they had changed their clinical practice. The course has resulted in increased use of transtracheal oxygenation with manual devices (Manujet(®), Enk(®)) and Seldinger cricothyroidotomy as well as paediatric difficult airway techniques such as paediatric sized elastic gum and Airtraq™ or fibrescopic intubation under general anaesthesia with spontaneous ventilation (through a laryngeal mask). CONCLUSION: These data encourage the training of experts in difficult airways. This curriculum is contributing to the dissemination of the recommendations among a large number of practitioners.

Peroperative electrocardiographic control of catheter tip position during implantation of femoral venous ports.

PURPOSE: Electrocardiographic (ECG) guidance has been shown to be as effective than fluoroscopy to position the tip of central venous devices close to the superior vena cava (SVC)-right atrium (RA) junction. When SVC access is contraindicated, a femoral access may be used. The aim of this prospective study is to evaluate the effectiveness of ECG guidance to position the tip of femoral ports at inferior vena cava (IVC)-RA junction. METHODS: Inclusion criterion was the need for femoral port implantation. After insertion of the dilator in the femoral vein, the catheter with the guide wire inside was introduced and the ECG signal collected at the tip of the guide (Celsite™ ECG, B. Braun, Germany) or via saline injected in the catheter (Nautilus™, Perouse, France). Fluoroscopy was performed at each change of the P-wave from IVC to RA. A final X-ray was performed after withdrawing the catheter 2 cm below the first P-wave change. RESULTS: A total of 18 patients were included between December 2011 and June 2013. The P-wave was most often negative in IVC, biphasic when the catheter entered RA and giant and positive at the top of RA. When the catheter was withdraw 2 cm below the first biphasic P-wave the tip was just below the IVC-RA junction in 17 patients. In one patient P-wave changes were not significant and the final position was adjusted under fluoroscopy. CONCLUSIONS: ECG guidance is effective to assess catheter tip position during femoral port placement and avoids the need for radiological methods.

Postoperative nausea and vomiting in the post-anesthetic care unit, a 5-year survey of a quality assurance program in surgical cancer patients.

INTRODUCTION: PostOperative Nausea and Vomiting (PONV)is a major side effect related to surgery and anesthesia. Our institution is equipped with Anesthesia Information Management System (AIMS). We used this database to assess and follow the effect of our quality assurance program for PONV. METHODS: Our AIMS system permits automatic storage of vital signs while other information are indexed by anesthesia providers and PACU personnel. Intra-operative and PACU events were extracted from a database by sequential query language (SQL) interrogation from year 2005 to 2010. A new prophylactic antiemetic protocol was issued for high-risk patients in our institution (dexamethasone, droperidol in the operating room and odansetron in the PACU) and initiated in 2006; in parallel, adjuvant measures influencing PONV were taken for anesthetic interventions. PONV scores and related medications, intra- and postoperative opioids and inhalational anesthetics consumption were extracted, and results were regularly shared with anesthesia providers and PACU personnel as part of quality assurance program. RESULTS: The study concerned 40,045 patients, exhaustivity or completeness was 70% in 2005 but reached 90% in 2010. PONV scores significantly improved during the years after the instauration of the new protocol (31% in 2005 vs. 13% in 2010). Concomitantly, morphine consumption and intra-operative nitrous oxide showed a steady decrease. No significant difference was noticed in the use of inhalational anesthetics. CONCLUSION: Using our AIMS database, we indirectly monitored the effectiveness of our PONV protocol but also other possible component of a multimodal approach toward these side effects.

Prognostic similarities and differences in optimally resected liver metastases and peritoneal metastases from colorectal cancers.

PURPOSE: To analyze and compare survival in patients operated for colorectal liver metastases (LM) with that in patients optimally resected for peritoneal metastases (PM). PATIENTS AND METHODS: This study concerns 287 patients with LM and 119 patients with PM treated with surgery plus chemotherapy between 1993 and 2009, excluding patients presenting both LM and PM. RESULTS: Mortality (respectively, 2.7% and 4.2%), morbidity (respectively, 11% and 17%), and 5-year overall survival (OS) rates (respectively, 38.5% and 36.5%) were not statistically different between the LM group and the PM group. Multivariate analysis showed that the extent of the disease was the main prognostic factor, which led us to divide the population into 5 subgroups. The best 5-year OS rate (72.4%) was obtained in patients with minimal peritoneal disease [peritoneal cancer index (PCI) ≤5]. OS was similar for the patients with less than 10 LM and those with a PCI between 6 and 15 (respectively, 39.4% and 38.7%). Five-year OS was lower in patients with more than 10 LM (18.1%), and dramatically low for patients with a PCI > 15 (11.8%). CONCLUSIONS: This study underlines the prognostic impact of the tumor burden in metastatic colorectal disease. In selected patients, similar survival rates can be obtained after optimal treatment of LM and PM. As the role of optimal surgical resection of LM is widely accepted, our results confirm that an optimal attitude should also be adopted to treat PM with a PCI < 16, particularly in patients with very low PCI (<5) where survival could be better than LM.

The use of a clinical database in an anesthesia unit: focus on its limits.

Anesthesia information management system (AIMS) can be used a part of quality assurance program to improve patient care, however erroneous or missing data entries may lead to misinterpretation. This study assesses the accuracy of information extracted for six consecutive years from a database linked to an automatic anesthesia record-keeping system. An observational study was conducted on a database linked AIMS system. The database was filled in real time during surgical/anesthesia procedure and in the post-anesthesia care unit. The following items: name of the anesthetist, duration of anesthesia, duration of monitoring, ventilatory status upon arrival in postoperative care unit, pain scores, nausea and vomiting scores, pain medication (morphine) and anti nausea and vomiting drug consumption (ondansetron) were extracted and analysed in order to determine exhaustivity (percentage of missing data) and accuracy of the database. The analysis covered 55,946 anaesthetic procedures. The rate of missing data was initially high upon installation but decreased over time. It was limited to 5% after 3 years for items such as start of anesthesia or name of the anesthetist. However exhaustivity/completeness of some other variable, such as nausea and vomiting started as low as 50% to reach 20% at 2008. After cross analysing pain and post-operative nausea and vomiting scores with related medication consumption, (morphine and ondansetron) we conclude that missing data was due to omission of a zero score rather than human error. The follow-up of quality assurance program may use data from AIMS provided that missing or erroneous values be mentioned and their impact on calculations accurately analysed.

Survey of muscle relaxant effects management with a kinemyographic-based data archiving system: a retrospective quantitative and contextual quality control approach.

In a retrospective quality control study of muscle relaxant management, we assessed unbiased files provided by an automatic archiving system using quantitative monitoring generated by a kinemyographic transducer and suggest improvements for a possible future design. 200 randomly selected files were double checked to collect the values of twitch height ratio (THr), train of four ratio (TOFr) and TOF count in four periods: references values acquisition (REF), maximal level of paralysis, paralysis maintenance, pre-tracheal extubation residual paralysis assessment (RPA). The parameter values were selected according to period-specific predefined rules. A quantitative quality control was based upon standardized cut-offs values. A contextual quality control was based upon the detection of "difficult-to-interpret" episodes. Results were expressed on a descriptive basis only. For the REF period, THrs and TOFrs were lacking in, respectively, 47 and 18 of the 200 recordings analysed. A starting TOFr above 0.90 existed in 119 files. Concomitant THrs and TOFrs >0.90 were evidenced 93 times. During RPA period, TOFr >0.90 was recorded on 82 occasions. The optimal combination of THr >0.80 and TOFr >0.90 was detected in 30 files only. Presence of "difficult to interpret" episodes started with 18 files for the REF period and increased to 42, 86 and 52 in the subsequent ones most of them probably related to the absence of initial calibration procedure. In the real life conditions, a near to optimal quality control is not always observable with the quantitative neuromuscular monitoring studied. To improve the NMT monitoring, the calibration of the sensor should be performed vigorously by the anaesthesia provider and the quality of this calibration must be displayed on the screen of the monitor.

Barriers to staff adoption of a surgical safety checklist.

OBJECTIVE: Implementation of a surgical checklist depends on many organisational factors and on socio-cultural patterns. The objective of this study was to identify barriers to effective implementation of a surgical checklist and to develop a best use strategy. SETTING: 18 cancer centres in France. DESIGN: The authors first assessed use compliance and completeness rates of the surgical checklist on a random sample of 80 surgical procedures performed under general or loco-regional anaesthesia in each of the 18 centres. They then developed a typology of the organisational and cultural barriers to effective checklist implementation and defined each barrier's contents using data from collective and semi-structured individual interviews of key staff, the results of an email questionnaire sent to the 18 centres, and direct observations over 20 h in two centres. RESULTS: The study consisted of 1440 surgical procedures, 1299 checklists, and 28 578 items. The mean compliance rate was 90.2% (0, 100). The mean completion rate was 61% (0, 84). 11 barriers to effective checklist implementation were identified. Their incidence varied widely across centres. The main barriers were duplication of items within existing checklists (16/18 centres), poor communication between surgeon and anaesthetist (10/18), time spent completing the checklist for no perceived benefit, and lack of understanding and timing of item checks (9/18), ambiguity (8/18), unaccounted risks (7/18) and a time-honoured hierarchy (6/18). CONCLUSIONS: Several of the barriers to the successful implementation of the surgical checklist depended on organisational and cultural factors within each centre. The authors propose a strategy for change for checklist design, use and assessment, which could be used to construct a feedback loop for local team organisation and national initiatives.