[Human Resources for Unplanned Activities in Obstetrics and Gynecology. Consensus statements by the CNGOF, CARO, CNSF, FFRSP, SFAR, SFMP and SFN]. / Ressources humaines pour les activités non programmées en gynécologie-obstétrique. Propositions élaborées par le CNGOF, le CARO, le CNSF, la FFRSP, la SFAR, la SFMP et la SFN.

OBJECTIVE: To determine a minimum threshold of human resources (midwives, obstetricians and gynecologists, anesthesiology and intensive care units, pediatricians) to ensure the safety and quality of unplanned activities in Obstetrics and Gynecology. MATERIALS AND METHODS: Consultation of the MedLine database, the Cochrane Library and the recommendations of authorities. Meetings of representative members in different modes of practice (university, hospital, liberal) under the aegis of and belonging to the French College of Obstetricians and Gynecologists (CNGOF), the French Society of Anesthesia and Resuscitation (SFAR), the French Society of Neonatalogy (SFN), the French Society of Perinatal Medicine (SFMP), the French College of Midwives (CNSF), the French Federation of Perinatal Care Networks (FFRSP) with elaboration of a re-read text by external experts, in particular by the members of the Boards of Directors of these authorities and of Club of Anesthesiology-Intensive Care Medicine in Obstetrics (CARO). RESULTS: Different minimum thresholds for each category of caregivers were proposed based on the number of births/year. These proposed minimum thresholds can be modulated upwards according to the types (level I, IIA, IIB or III) or the activity (existence of an emergency reception service, maternal-fetal and/or surgical activity of resort or referral). Due to peak activity and the possibility of unpredictable concomitance of urgent medical procedures, it is necessary that organizations plan to use resource persons. The occupancy rate of the target beds of a maternity ward must be 85%. CONCLUSION: These proposed minimum thresholds are intended to help caregivers providing non-scheduled perinatal as well as Obstetrics and Gynecology care to make the most of the human resources allocated to institutional bodies to ensure their safety and quality.

[Morbidity/mortality review: usefulness and shortcomings]. / Revue de mortalité et de morbidité (RMM): apports et freins.

GOAL: The Morbidity-Mortality Conference is a formalized exercise validated by the Haute Autorité de Santé (HAS) whose aim is to improve the quality and safety of care through periodic (weekly or monthly) analysis of deaths and complications. In France, no data is available concerning the implementation of the MMC methodology despite the interest of the National Institute of Healthcare Quality (HAS) in using the MMC as part of the physician recredentialling process and of hospital accreditation (mandatory in France since the laws of 2005 and 1997 respectively). We aimed to study the experience and perceptions of physicians with this specific methodology in the context of a large regional project aimed to improve clinical risk management. METHODS: A one page questionnaire with eight confidential questions and a space for free commentary was sent to 150 hospitals in the north of France. RESULTS: We received 83 responses from 29 hospitals (range: 1-14 responses per hospital). Analysis of unexpected adverse events is performed mainly in informal meetings (76%) and mandatory reports (77%); the MMC methodology is rarely used (11%). The analysis of adverse events is considered to be an important tool for the improvement of patient care and safety (90%) and continuing education (61%), and it results in modification of care protocols (70%) or organizational change (71%). Lack of knowledge of the MMC methodology (66%) and lack of available time (50%) are the main obstacles to the adoption of the MMC. Fear that the findings of the MMC could be available for use in litigation (1%) was not an obstacle. Physicians interested in implementing the MMC are motivated by a desire for improved patient safety (86%) and care management on the surgical service (54%). Self-responsibility is more important than the mandatory process for re-credentialing. CONCLUSION: The implementation of the MMC requires specific measures such as teaching and support.

Central venous catheter-related complications in newborns and infants: a 587-case survey.

In an attempt to identify factors determining central venous catheter-related complications in newborns and infants, 587 cases have been retrospectively analyzed. Attention has been paid to the influence of the incidence of babies' body weight, site of insertion, and technique of placement of the catheter and the material used, ie, silicone (SI) or polyurethane (PU). Overall complications occurred in 28% of the catheters with 2 deaths due to cardiac tamponade. Mechanical complications happened in 22% of the catheters, including dislodgement (11.6%), extracorporeal perforation (5.3%), and obstruction (5%). Septic complications occurred in 4% catheters, including proven bacteriemia (2.5%), abscess at the entry site (1%), and isolated fever (0.8%). Clinically evident caval thrombosis occurred in 1% of the catheters. Overall complications were significantly higher when the body weight was lower than 2,500 g (P less than .01) due to a significantly higher incidence of septic complications (P less than .05). When a proximal site of placement of the catheter was used, both septic and mechanical complications were more frequent than in the distal approach (P less than .01). The incidence of complications was similar in surgically and in percutaneously placed catheters as in SI and PU catheters. Nevertheless, fatal complications occurred only in PU catheters, leading us to avoid the choice of such material in newborns and small infants.

[Management of anxious and painful manifestations in pediatric uroradiology]. / Prise en charge des manifestations anxieuses et douloureuses en uroradiologie pédiatrique.

Two hundred and seven children undergoing either intravenous pyelography (i.v.p.) or voiding cystourethrography (VCUG) were examined. Under the age of 5 years, children received intra-rectal midazolam (0.5 mg/kg) with a maximum of 5 mg. Children over 5 years, self-inhaled an equimolar mixture of oxygen and nitrous oxide. Pain and stress were evaluated in children under 5, by the pediatric radiologist according to the 4 non verbal items of the Le Baron-Zeltzer scale and in children over 5 by the child himself with a visual analogic scale. Under 5 years of age, midazolam significantly reduced pain and stress during i.v.p. (p < 0.0001), VCUG both in boys (p < 0.0001) and girls (p < 0.0001). In children over 5, nitrous oxide inhalation reduced pain during i.v.p. (p = 0.0004), during VCUG in girls (p = 0.0025), but not in boys ((p > 0.05). Pediatric radiologists should evaluate pain and stress in their patients as they can be easily and safely limited.

[Anesthesia for laparoscopic surgery in pediatrics]. / Anesthésie pour coeliochirurgie en pédiatrie.

The increasing use of laparoscopic surgery in children is associated with the enlargement of the spectrum of indications to appendicectomy, extramucosal pylorotomy and cure of oesophageal reflux. It is also linked with new problems, mainly due to physiologic modifications elicited by pneumoperitoneum and patient's posture. Although sufficient data are not yet available, the respiratory and cardiovascular modifications are probably similar to those occurring in adults, at least in children more than 4-month-old, as long as the intra-abdominal pressure remains under 15 mmHg. The use of higher intra-abdominal pressures has not been reported in children. In this case, the cardiovascular changes consist mainly in an increase in arterial pressure. In some children, non specific decreases in heart rate and in blood pressure can be observed. The latter can be elicited by a surgical complication, hypovolaemia, head-elevated position or deep anaesthesia. In the newborn and infant under 6 months, intra-abdominal pressures of 15 mmHg or more carry a risk of low cardiac output due to a decrease in contractility and compliance of the left ventricle. In this group of age it is therefore recommended to establish a pressure not higher than 6 mmHg. Moreover, in these very young children, the risk for reopening of the right-left shunts can result in heart insufficiency and systemic gas embolism. Peroperative respiratory changes include an increase in PetCO2 and more rarely a decrease in SaO2. The interpretation of the former depends on the site of gas sampling in the anaesthetic system. It is easily controlled by an increased minute ventilation. Various causes, such as bronchial intubation, inhalation of gastric contents or gas embolism, can decrease SaO2. Contra-indications for laparoscopic surgery include hypovolaemia, heart diseases, increased intracranial pressure and alveolar distension. Therefore newborns are patients at high risk in so far as their foramen ovale or their ductus arteriosus is patent, the pulmonary arterial resistances remain increased and a bronchodysplasia is existing. In some cases a special disease is often associated. As an example recurrent bronchitis or asthma is associated with an oesophageal reflux and a sickle-cell disease in patients with cholelithiasis. These patients require special pre-, per- and postoperative care for prevention of complications. Anaesthesia for laparoscopic surgery does not require a major extension of the usual security regulations. Special attention must be paid to arterial pressure. Therefore end-expiratory concentration of the halogenated anaesthetic agent should not be kept higher than 1.5 times the MAC related to the age during maintenance of anaesthesia.(ABSTRACT TRUNCATED AT 400 WORDS)

[Comparison of the pharmacokinetics of etomidate in children and in adults]. / Comparaison de la pharmacocinétique de l'étomidate chez l'enfant et chez l'adulte.

Etomidate pharmacokinetics were compared in 12 children (P group) (age 7 to 13 years, weight 22 to 48 kg) and in 4 adult women (A group) (age 28 to 52 years, weight 46 to 72 kg), A.S.A. 1, undergoing minor non abdominal surgery. They were unpremedicated and anaesthetized with alfentanil 100 micrograms.kg-1, and isoflurane 2 vol % in N2O/O2 (1/1). Etomidate was administered as a bolus: 0.3 mg.kg-1 in adults and 0.4 mg.kg-1 in children. Venous plasma samples were frozen until further etomidate assay with a HPLC technique. In all patients but two children, data were fitted to a three rather than a two compartment model. Differences between groups (mean +/- SD values) included Vdc (P: 0.66 +/- 0.31 l.kg-1; A: 0.27 +/- 0.15 l.kg-1; p less than 0.01), t1/2 pi (P: 5.4 +/- 2.9 min; A: 2.7 +/- 5.7 min; p less than 0.05) and plasma clearance (P: 17.2 +/- 4.6 ml.kg-1.min-1; A: 10.9 +/- 3.3 ml.kg-1.min-1; p less than 0.05). No statistical difference was found between A and P groups for the following parameters: t1/2 alpha (37.1 +/- 12.0 min vs 26.8 + 15.1 min), t1/2 beta (260 +/- 99 min vs 175 +/- 99 min), Vdss (2.5 +/- 1.11.kg-1 vs 2.8 +/- 1.61.kg-1), Vd beta (4.1 +/- 2.41.kg-1 vs 4.0 +/- 2.21.kg-1), and MRT (228 +/- 80 min vs 172 +/- 101 min). No age-related difference was found inside P group with regard to pharmacokinetic parameters. In conclusion, a 30% higher etomidate bolus dosage is required in children than in adults to achieve similar plasma concentrations, due to a higher volume of the initial compartment. In comparison to adults the higher clearance suggests higher maintenance dose requirements in children.

[Laparoscopic surgery in pediatrics: the point of view of the anesthetist]. / Coeliochirurgie en pédiatrie: le point de vue de l'anesthésiste.

Data were collected from a retrospective audit in anaesthetists members of the French Association of Anaesthetists in Paediatrics (ADARPEF) and from the prospective study of the author's practice of appendectomy using open or laparoscopic surgery. Retrospective data obtained in 9 of the 16 answering centres show that contraindications include respiratory disability, cardiopathy and age lower than 5 years when surgical instruments of proper size are not available. Monitoring included electrocardioscope, non invasive arterial pressure, pulse oximetry and capnography. Three centres excluded halothane due to possible cardiovascular concern. In two institutions N2O was omitted to limit the size of potential gas embolism. Intraoperative events included high PETCO2 (37%), high arterial pressure (10%), low arterial pressure (3%), bradycardia (1%), hypoxia (0.5%) and one case of pneumothorax. In the appendectomy series, laparoscopy increased the duration of the procedure, and therefore intraoperative opioids requirements. Arterial pressure was higher in this group, irrespective to intraabdominal pressure and to PETCO2. No significant improvement in postoperative analgesia was found. It is therefore recommended to pay special attention to intraoperative anaesthetic and surgical management of children undergoing laparoscopic surgery, particularly in newborns and infants. The high incidence of minor intraoperative adverse events should be balanced by increased postoperative benefit to the patient which has not yet been demonstrated in children.

[Physiology of nodal tissue and effect of products used in anesthesia]. / Physiologie du tissu nodal et effet des produits employés en anesthésie.

The three fundamental properties of the nodal tissue, i.e.: excitability, automaticity and conduction of the depolarisation wave, are directly dependent on ionic transmembrane currents. These currents, either active or passive, determine the characteristics of the membrane action potential. Passive ionic movements cross gated transmembrane channels which activation is voltage-dependent, sometimes time-dependent and, for Ca2+ channels, dependent on intra-cellular cyclic AMP content. Both intra and extra-cellular ionic concentrations (K+, Ca2+, Mg2+) alter these passive movements. Active ionic movements require ATP hydrolysis and depend only on cellular metabolism. The neurovegetative system and its transmitters modulate the nodal tissue function altering passive ionic currents. Drugs employed during anesthesia change this function either by direct action on the ionic currents or by indirect action on the neurovegetative system or on histamine liberation. Thus: local anesthetics block selectively fast sodium channels; halogenated volatile anesthetics inhibit slow calcium channels: and narcotics are quite always vagomimetics, sometimes sympathicolytics, they often release histamine. Nevertheless, mechanism of action of various drugs remain unclear.

[The importance of the preoperative measurement of hemoglobin concentration. Evaluation of a colorimetric method (Hemocue)]. / Intérêt de la mesure peropératoire de la concentration d'hémoglobine. Evaluation d'une méthode colorimétrique (Hemocue).

The present study compares two methods of haemoglobin measurement during surgery in 40 patients aged 1 to 85 years. The reference method is the Coulter STKS based on red cell count and mean cellular content in haemoglobin measurement. The method tested (Hemocue-Diagnostics Transfusion) allows instantaneous determination of haemoglobin on a 10 mu sample by measuring infrared absorption by haemoglobin in the 565 and 880 nm wavelengths. These methods have been compared using the method of assessment of agreement described by Bland and Altman. As previous reports suggested that the precision of haemoglobin measurement by Hemocue could depend on the capillary or venous site of sampling, we assessed agreement of the two methods of measurement of haemoglobin at both sites. In addition, the relationship between hematocrit and haemoglobin measured by either method has been assessed. On venous samples, there was a good agreement between the two methods of measurement of haemoglobin (n = 47), with a mean difference of -0.166 g/dl-1 and agreement limits of -1.041 g/dl-1 and +0.195 g/dl-1. Ninety six percent of the observed differences to two methods were within the 95% confidence interval. On capillary samples, there was a poor agreement between Hemocue and Coulter since the mean difference was -0.272 g/dl-1 with the following limits of agreement: -2.356 g/dl-1 and +1.812 g/dl-1. Only 92% of the observed differences were within the 95% confidence interval, with 17% of these being greater than the clinically accepted limit of 1 g/dl-1. The precision of Hemocue measurement of capillary blood haemoglobin was only +/- 16%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hemodynamic effects of etomidate in the child: a study of the dose-effect relation]. / Effets hémodynamiques de l'étomidate chez l'enfant: étude de la relation effet-dose.

In order to determine haemodynamic effects of increasing etomidate dosage, 18 healthy anaesthetized children aged 3 to 8 years were randomly given etomidate as a bolus: 0.125 mg/kg (group I; n = 6), 0.25 mg/kg (group II; n = 6) or 0.5 mg/kg (group III; n = 6). Heart rate (HR), mean arterial pressure (MAP). Doppler aortic flow (DAF) and equivalents for systolic index (SI) and systemic vascular resistances (SVR) variations after etomidate administration were compared. Spearman's rank correlation test shows a significant relationship between increasing etomidate dosage and both decreased SI and increased SVR. This suggests to decrease dosage when reducing SI is unlikely.

[Postoperative analgesia in children]. / Analgésie post-opératoire chez l'enfant.

Postoperative analgesia remains frequently insufficient in children. This is in part due to the difficult assessment of pain in the different age groups. In addition, analgesics are commonly ordered inadequately, especially with regard to age-dependent changes in their pharmacokinetics. This often leads to an inadequate administration of different drugs. The different analgesic drugs and techniques available allow to establish guidelines for postoperative analgesia in different age groups of children, under different surgical and postoperative conditions. On the basis of such guidelines, ordered analgesics have a greater chance to be really administered at the proper time to each child.

Cardiorespiratory changes during laparoscopic fundoplication in children.

The results of a prospective assessment of cardiorespiratory changes related to anaesthesia and laparoscopic Nissen fundoplication are described in 25 children aged 1.2 to 14.3 years, weighing 9.0 to 64.0 kg. Respiratory disease or oesophagitis were present in 68% cases. During balanced inhalational anaesthesia, hypotension or bradycardia occurred prior to peritoneal insufflation in three cases of reverse Trendelenburg position. During surgery, intra-abdominal pressure was in the 6-10 mmHg range. Transiently, two patients were hypotensive while ten were hypertensive. PETCO2 gradually increased but only two patients required increased minute ventilation. One bronchial intubation episode developed. Airway complications were related to isoflurane administration. Postoperatively, transient hypoxia (25% cases) was observed during the first 3 h. Analgesia duration was in the 40-1440 min range. Hospital stay was 5.6 +/- 1.5 days (mean +/- SD). Laparoscopic paediatric fundoplication is safe when hypovolaemia and postoperative hypoxia are prevented.