[Activity-based financing: is ambulatory care profitable for the institution]. / T2A et chirurgie orbitopalpébrale : l'ambulatoire est-il vraiment rentable pour l'établissement ?

INTRODUCTION: The aim of this study was to evaluate the impact of the 11th version of the National Health System's Activity-Based Financing on the income of a University Hospital department for palpebral, lacrimal, and orbital surgeries. PATIENTS AND METHODS: The number of such surgeries in 2008 was based on the Medicalization Program of the Information System. Using the 11th version of the Activity-Based Financing for Diagnosis-Related Groups, we compared the income in both inpatient and outpatient settings. RESULTS: Two hundred and forty-eight patients undergoing palpebral, lacrimal, or orbital surgery between January and December 2008 were included, with 87% treated on an outpatient basis. The lower reimbursement for outpatient surgery resulted in a loss of 184,500 euros (79%) for our department compared to the inpatient procedure. DISCUSSION: With rigorous organization, ambulatory surgery is feasible for palpebral, lacrimal, and orbital surgery. Nonetheless, with department incomes related to activity, ambulatory care seems financially disadvantageous. Many departments are trying to develop an ambulatory structure, but the need to balance their budget requires improved coherence.

[Disposable vs reusable laryngeal mask airway: a cost-minimization analysis]. / Masques laryngés à usage unique vs réutilisable : une étude de minimisation de coûts.

JUSTIFICATION: According to French regulations concerning the risk of Creutzfeldt-Jakob disease transmission, traceability procedures of all sterile medical devices which need to be reused are mandatory. Despite sterilization processes, the reusable laryngeal mask airway (LMA) prion disease transmission remains possible. As a result, the disposable LMA has been introduced. OBJECTIVE: Assuming clinical equivalence was achieved, the cost of disposable vs reusable LMA was studied in a university hospital. STUDY DESIGN: A Cost-minimization analysis of disposable vs reusable laryngeal mask airway was realised. METHODS: Disposable LMA cost was calculated as the sum of product cost and elimination cost. Reusable LMA were autoclaved after hospital purchasing in two separate sterilizing processing units of the same hospital. Reusable LMA cost was determined combining materiel and labor costs. RESULTS: The reusable LMA cost depended on the sterilizing processing unit concerned and varied between 9.59 Euros and 9.69 vs 8.38 Euros for the single-use LMA. CONCLUSION: With the cost savings made possible by use of disposable LMA in both labor and consumables, this practice should be considered.

[Allergy investigations after two cases of adverse reactions to a neuromuscular blocking agent and management for subsequent general anaesthesia]. / Bilan allergologique après un choc anaphylactique à un curare non dépolarisant: conduite à tenir pour une anesthésie ultérieure.

We report two cases of severe anaphylactic reactions to rocuronium. Diagnosis was confirmed by skin tests and specific IgE assay. Cross-reactivity to all neuromuscular blocking agents was investigated by intradermal tests and leucocyte histamine release test. Intradermal tests and leukocyte histamine release were negative for cisatracurium. The two patients had undergone a subsequent general anaesthesia using cisatracurium and did not present any adverse reaction.

[Adsorption of carbon dioxide gas]. / Absorption du gaz carbonique.

OBJECTIVES: To analyse the various methods for carbon dioxide absorption in anaesthesia, the available absorbents and their modes of use. DATA SOURCES: We searched the Medline and Internet databases for papers using the key words: carbon dioxide absorption, soda-lime, zeolite. We also had correspondence and contacts with soda lime manufacturers. STUDY SELECTION: All types of articles containing data on CO2 absorption. DATA EXTRACTION: The articles were analysed for the benefits and adverse effects of the various absorbents. DATA SYNTHESIS: Carbon dioxide absorption enables the use of low flow anaesthesia, and a decreased consumption of medical gases and halogenated anaesthetics, as well as reduced pollution. Chemical absorbents (soda-lime and barium hydroxide lime (Baralyme) may produce toxic compounds: carbon monoxide with all halogenated anaesthetics and compound A with sevoflurane. Simple measures against desiccation of the lime prevent carbon monoxide production. The toxicity of compound A, shown in the rat, has not been proven in clinical anaesthesia. Recent improvements in manufacture processes have decreased the powdering of lime. Moreover, filters inserted between the anaesthesia circuit and the patient abolish the risk for powder inhalation.

[Controlled hypotension? Watch the capnograph closely!]. / Hypotension artérielle contrôlée? Ayez l'oeil sur le capnographe!

During the surgery of the middle ear, a profound general anaesthesia associated to the monitoring of arterial hypotension may obtain a fiel of operation free of any blood. The patient surveillance needs the modern techniques of monitoring. SaO2 is altered only for severe falls of mean arterial pressure. PetCO2 reflects three factors: the cellular metabolism that is stable under general anaesthesia, the ventilatory conditions which are controlled and haemodynamic conditions. The cellular metabolism and the ventilatory being stable, PetCO2 modifications reflect mean arterial pressure variations. We have observed minimal falls of PetCO2 (2-3 mmHg) accompanying falls of mean arterial pressure. Monitoring mean arterial pressure every 5 minutes neglects periods of time. On the contrary capnography allows a constant haemodynamic survey. The capnography seems to be a precious help during the technique of controlled arterial hypotension.

[Emergencies in ORL: management by the anesthesiologist]. / Les urgences en ORL: conduite à tenir par l'anesthésiste.

The otorhinolaryngologic (O.R.L.) diseases seen in the emergency room are frequent and diverse. Most of them need the otorhinolaryngologist and anaesthetist to be present in order to realise fast, adequate and, above all, well coordinated gestures. The foreign bodies, the hemorrhagies, the traumas, the infectious diseases and finally the respiratory distress can be classified by frequency order. The laryngo tracheal dyspneas (DL) are first considered because they are the most dramatic emergencies: infectious DL in children, DL secondary to tracheal intubation or tracheotomy, DL caused by a tumor, traumatic DL secondary to a knock, a blast, a burn or a thyroidectomy, edematous DL and "DL after tracheotomy". The infectious O.R.L. emergencies are observed in the serious pharyngeal diseases, in the cervical cellulitis and during the complications of sinusitis or mastoiditis. The foreign bodies (CE) are the most frequent cause of O.R.L emergencies. The complications depends of the location of the foreign: almost nonexistent if the CE is located in the nasal fossa or in the meatus acusticus externus, inconstant if CE is oropharyngeal or oesophageal. The complications may be fatal if CE is pharyngotracheal and are relevant to the exact location of CE which result in emergency behavior. The considered oesophageous lesions not due to CE are chemical burns and perforations; in emergency, hemorrhagic O.R.L. lesions only epistaxias are concerned; O.R.L. hemorrhage need to be studied with their specific causes.