[How to manage analysis and feedback of adverse events in transfusion]. / Analyse d'un incident de la chaîne transfusionnelle et gestion du retour d'expérience.

Analysing adverse events is part of the medical practice in so far as the part it plays is outstanding in terms of feedback and improved healthcare safety. The integrated implementation of this practice is based on a four-dimensional system: strategic (corporate policies), cultural (safety-oriented cultural mindset), structural (dedicated organization and resources) and technical (methodologies and utilities). Two case studies illustrate the sequencing process from selecting the to-be-analyzed event down to figuring out the appropriate action plan. Beyond the visible and obvious origin, thanks to the implemented methods such as causal tree or ALARM method, far-fetched analysis elements and identified factors likely to explain events can be discovered. Comments on the role and terms of feedback are also hereto expressed.

Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy.

We prospectively analyzed the outcome of lobectomy in a cohort of 67 patients. Operative time, postoperative pain, pulmonary function, and early outcome were compared between the patients undergoing video-assisted techniques (n = 44) and those undergoing standard muscle-sparing procedures (n = 23). Pain was quantified daily throughout the first week using the visual analog scale. The forced expiratory volume in 1 second and the forced vital capacity were measured at days 2, 4, and 8 postoperatively. The operative time was significantly longer (p < 0.02) and the postoperative pain was significantly less (p < 0.006) in the group undergoing video-assisted procedures. Pain-related morbidity, the mean duration of air leaks, the duration of chest tube placement, and the hospital stay were all less in the video-assisted group, but the differences did not reach statistical significance. However, the impairment in pulmonary function and the overall morbidity were identical for the two groups. Based on our findings, we conclude that video-assisted minithoracotomy is a safe and reliable approach for performing lobectomies, and that the decreased postoperative pain associated with this minimally invasive approach does not result in preserved pulmonary function and significantly reduced morbidity when compared with a muscle-sparing thoracotomy.

Video-assisted repair of a ruptured right hemidiaphragm.

Video-assisted thoracic surgery is emerging as a viable approach to increasingly complex intrathoracic therapeutic procedures. We present a case of delayed diagnosis of a ruptured right diaphragm caused by a closed trauma in a young woman. The diaphragm was repaired successfully using a video-assisted procedure. Limited postoperative chest pain and muscular impairment allowed early physical therapy that resulted in an excellent outcome. Video-assisted thoracic surgery is suggested as a new treatment option for traumatic diaphragmatic disorders.

Is lung cancer resection justified in patients aged over 70 years?

From January 1980 through January 1985, 452 consecutive patients underwent pulmonary resection for primary non-small cell bronchogenic cancer. Forty-seven patients (10.4%) were 70 years old or older: there were 45 men and 2 women, with a mean age of 72.4 years (S.D.: 2.6; range: 70-79). This population was comparable to the 405 younger patients with respect to the type of resection, histology and TNM staging. Whereas the non-fatal complication rate was similar in both groups (25.5% versus 29.9%), the in-hospital mortality rate was significantly higher in the older patients (12.8% versus 4.7%; P < or = 0.05). The mortality rate after extended resections was significantly higher among the older patients (33.3% versus 6%, P < or = 0.01). The cause of death was myocardial infarction in half the cases; the underlying coronary disease was unrecognized preoperatively in one-third. Five-year survival was comparable in both groups: 29.8% and 33%, respectively. We conclude that pulmonary resection for bronchogenic cancer is justified in patients over 70 years; a careful preoperative assessment ought to be performed and standard resections should be preferred.

Major pulmonary resection by video assisted mini-thoracotomy. Initial experience in 35 patients.

Video-assisted thoracic surgery is emerging as a viable approach to increasingly complex intrathoracic therapeutic procedures. From February to July 1993, 35 patients (25 male, 10 female; mean age = 60 years, range: 17-74) underwent a major pulmonary resection using a video-assisted technique: lobectomy (n = 30) or pneumonectomy (n = 5). Pathology disclosed bronchogenic carcinomas (n = 26), metastases (n = 3), and miscellaneous disorders (n = 6). All procedures required one 10.5 mm port for the video-camera, one 3.5 to 5 cm utility thoracotomy through which surgical instrumentation was inserted and the operative specimen removed, and one occasional supplementary 12 mm port. Lung resections were performed with separated dissection and division of each component of the pedicle. The mean operative time was 145 min (SD: +/- 17). There were two postoperative deaths (5.7%) that were not directly related to the technique. Seven patients (20%) experienced non-fatal complications. After lobectomy, the mean duration of chest tube placement was 7.3 days (SD: +/- 1.6). The mean hospital stay was 11 days (SD: +/- 3). All the patients experienced minor postoperative chest pain. We conclude that video-assisted lung resections are technically feasible without an increased risk.

[Prolonged epidural analgesia following thoracotomy. Clinical study and serum levels over five days]. / Analgésie péridurale prolongée après thoracotomie. Etude clinique et taux sériques pendant cinq jours.

Prolonged continuous epidural analgesia allows perithecal infusion with fentanyl and bupivacaine for 5 postoperative days after thoracic surgery. This study included 27 thoracotomized patients randomised into two groups: group X consisted of 15 subjects, group Y consisted of 12 subjects. Each patient received 33 micrograms/hr or fentanyl for 48 hours, associated with 0.25% bupivacaine in group X, and 0.125% bupivacaine in group Y. Over the three last days, the infusion rate of both drugs was decreased in the two groups. No significant clinical difference appeared between X and Y. No clinical respiratory depression occurred. In group Y, mean plasma bupivacaine concentrations remained significantly lower (p less than 0.05). Mean fentanyl levels did not increase beyond 0.8 ng/ml. The use of 0.125% bupivacaine improved the margin of safety but did not impair clinical analgesia in the study. This method provides good analgesia for thoracotomized patients.

[Bronchial cancer associated with atheromatous arteriopathy. Prognostic and therapeutic consequences in pulmonary excision]. / Association cancer bronchique et artériopathie athéromateuse. Conséquences pronostiques et thérapeutiques dans la chirurgie d'exérèse pulmonaire.

Between January 1980 and January 1985, 462 consecutive patients underwent lung resection for bronchogenic carcinoma. Eighty of these patients (17.3 percent) had atherosclerosis involving mainly the coronary arteries (40 percent). The mortality rate was significantly higher in patients with atherosclerosis (10 percent) than in those without it (4.7 percent), but the long-term survival was not affected with the presence of atherosclerosis. The lung carcinoma-atherosclerosis association raises two problems: what investigations should be carried out in this group of patients at risk, and what treatment should be given priority when vascular lesions are present and likely to become complicated by pulmonary surgery? However, the presence of atherosclerosis should not lead to a re-evaluation of the need for lung resection.

[Interest of a collaboration between the vigilances' coordination and care-related risks management committees in a health care center]. / Intérêt d'une collaboration entre la coordination des vigilances et la gestion des risques liés aux soins dans un établissement de santé.

Health care vigilance committees appeared with time in France. Some vigilance entities are present at a regional level, but all are found at the National Drugs and Health Care Products Safety Agency. Along with health care centers' certification, vigilance committees' coordination has evolved: whereas its presence was optional in the first version of certification, it has now imposed itself within health care centers with the more recent versions of certification, detailing the actions it must undertake. In parallel, a lot of attention is put on health care-related risk management with a health care center. Vigilances' coordination can thus take advantage of this in sharing an incident declaration system common with that of health care-related risks management. This collaboration will enable the generation of a priori risks' maps, help analyze adverse events and use the notion of criticality within a global safe care policy in each health care facility.

[Endoscopic resection in bronchology using the YAG laser. Evaluation of a 5-year experience]. / Résection endoscopique au laser YAG en bronchologie. Bilan d'une expérience de 5 ans.

The authors describe their experience with 1222 tracheobronchial endoscopic laser resections. The technique uses the thermal effects of the YAG laser which can be set to produce coagulation and vaporization. In most cases, the rigid bronchoscope under general anesthesia was preferred to the flexible fiberscope under local anesthesia. The main reason for this preference is that the rigid system allows management of hemorrhage should it occur. The technique is described with special attention to prevention of hypoxia, the major hazard. Inoperable malignant tumors accounted for 50% of the procedures. The other indications were tumors with uncertain prognosis, benign tumors, tracheal stenosis, and miscellaneous lesions. Results depend greatly on location. No fatality was recorded during the procedure, but two deaths did occur in the 48 hours thereafter. The authors conclude that endoscopic laser resection is a very effective modality for obstructive lesions in the main airways. It can be repeated as many times as needed and may be associated with other forms of therapy.

Lower oesophageal reflux during priming with vecuronium.

We have studied the effects of vecuronium given in divided doses (priming principle) on the frequency of acid reflux into the oesophagus. Two groups of 16 patients were studied. After induction with thiopentone 6 mg kg-1 and fentanyl 3 micrograms kg-1, patients in one group were given vecuronium 0.01 mg kg-1 as a priming dose, followed by an intubation dose of 0.1 mg kg-1 4 min later. Patients in the other group were given no priming dose. Lower oesophageal pH was monitored continuously and acid reflux was defined as a decrease in pH to less than 4.0. One patient in each group had acid reflux during the time course of the induction. This study suggests that vecuronium 0.01 mg kg-1 given as a priming dose does not increase the risk of acid reflux into the oesophagus.

Pharmacokinetics and tissue penetration of a single dose of ceftriaxone (1,000 milligrams intravenously) for antibiotic prophylaxis in thoracic surgery.

The pharmacokinetics and tissue penetration of ceftriaxone after a single intravenous injection of 1,000 mg to 17 patients for antibiotic prophylaxis in thoracic surgery were studied. The patients were scheduled for elective noncardiac thoracic surgery. Adequate levels in serum (higher than or equal to the MIC for 90% of isolates of Staphylococcus aureus, Streptococcus spp., Escherichia coli, Haemophilus influenzae, and Klebsiella pneumoniae) were found for all patients throughout the surgical procedures. Mean maximal (5-min) and final (24-h) ceftriaxone levels in serum were 157 +/- 42 and 8.6 +/- 4.5 mg/liter, respectively. The beta-phase elimination half-life was 8.6 +/- 3 h, the plasma clearance was 18.4 +/- 6.25 ml/min, and the apparent volume of distribution at steady state was 0.21 +/- 0.07 liters/kg. At the time of the thoracotomy, the ceftriaxone concentrations were 13.5 +/- 7.8 micrograms/g in thoracic wall fat and 27 +/- 9 micrograms/g in lung tissue. At the time of closure, the ceftriaxone concentration was 15 +/- 9 micrograms/g in thoracic wall fat. During the different steps of the surgical procedures, 100% of patients had adequate levels in tissue (higher than or equal to the MIC for 90% of isolates of Streptococcus spp., E. coli, H. influenzae, and K. pneumoniae). For S. aureus, 90 to 100% of patients had adequate tissue ceftriaxone levels.

Measurement of lower oesophageal pH during induction of anaesthesia: use of oesophageal probe.

Gastric contents regurgitation into the oesophagus during induction of anaesthesia may easily fail to be recognized. The incidence of this complication was investigated in 59 consecutive patients. They were scheduled for elective thoracic surgery. Anaesthesia was induced with thiopentone (6 mg.kg-1), fentanyl (3 micrograms.kg-1), and either atracurium (0.4 mg.kg-1), vecuronium (0.1 mg.kg-1) or suxamethonium (1.5 mg.kg-1). Oesophageal pH was monitored with an oesophageal pH probe, connected to a portable computer. The pH probe had a virtually instantaneous response time and was positioned in the lower oesophagus. Acid reflux was defined as a decrease in pH to less than 4.0. During the course of induction, three patients (5%) presented an episode of acid reflux. No patient presented any clinical or radiological signs of pulmonary aspiration. This study suggests that monitoring oesophageal pH is a simple method of detecting gastric reflux during the period of induction.

Diagnosis by video-assisted thoracoscopy of traumatic pericardial rupture with delayed luxation of the heart: case report.

Isolated pericardial rupture is probably a frequently overlooked injury. We present a case of delayed heart herniation through a left pericardial tear resulting from blunt trauma. Diagnosis was achieved by video-assisted thoracoscopy, which was also helpful in the selection of the appropriate site and extent for the thoracotomy incision.