Driving performance of outpatients achieving discharge criteria after deep sedation is worse than these of their escort-driver: a prospective observational study on simulator.

Background: Achieving post-anesthesia discharge criteria after surgery or outpatient procedures does not mean that the patient has regained all his or her faculties, such as driving. Although mandated by many clinical guidelines, there is no evidence that escort-drivers reduce the risk of traffic accidents after deep sedation. The purpose of this study was to evaluate that hypothesis that driving performance as measured using a driving simulation would not differ between patients who had undergone deep sedation for gastrointestinal endoscopy meeting discharge criteria and their escorts. Methods: This prospective study included patients scheduled for ambulatory gastrointestinal endoscopy under deep propofol sedation (patient group) and their escorts (escort group). Driving performance of escorts and patients (when discharge criteria were met) was assessed using a driving simulator. Results: 30 patients and their escorts were included. Patients crossed the midline significantly more frequently than escorts (3 [2-4] (median [IQR]) and 2 [1-3] crossings, respectively, p=0.015]. Patients were speeding for a higher proportion of the distance traveled compared with escorts (37 (20)% (mean (SD)) and 24 (17)% in patients and escorts, respectively, p = 0.029). There were no significant differences between groups in other simulation parameters. Conclusions: The ability to stay within the traffic lanes, as measured by the number of midline crossing during a simulated driving performance, is impaired in patients who meet discharge criteria after gastrointestinal endoscopy under deep sedation compared with their escorts. This finding does not support a practice of allowing patients to drive themselves home after these procedures.

Two different techniques of facial mask induction of anesthesia in children provide identical intubation conditions despite different anesthetic depth.

BACKGROUND: Sevoflurane induction in chil- dren is performed using different techniques. Constricted, centered, and symmetrical pupils (CCSP) are classically the endpoint to be achieved before laryngoscopy is performed. OBJECTIVES: We investigated whether two different inhalation induction techniques with the same clinical end- point provided similar intubating conditions and comparable depth of anesthesia as assessed by the Bispectral Index (BIS). METHODS: Following IRB approval, and informed parental consent, 20 children were recruited. They were sched- uled for general anesthesia with tracheal intubation, and randomly assigned to Group 1, where the practitioner used 6% inspired sevoflurane in 50% 02/N20, and no manually assisted ventilation, or Group 2, where inspired sevoflurane was 8% in 50% 02/N20, and ventilation was manually supported upon loss of consciousness. BIS values were blinded. Laryngoscopy was performed after CCSP. Intubation conditions scoring was based on jaw relaxation (mobile = 1, partially mobile = 2, fixed = 3), position of vocal cords (open = 1, half-closed = 2, closed = 3), and cough (no cough = 1, 1 or 2 coughing efforts = 2, persistent coughing = 3). A total score > 3 corresponded to non-optimal conditions. RESULTS: Upon CCSP, BIS values were significantly lower in Group 1 [mean (SD) : 30 (8) - 48 (18), p <0.001], despite significantly higher end-tidal sevoflurane concentration in Group 2 [mean (SD) : 5.0 (0.7) - 6.2 (0.5) ; p <0.001]. Time to CCSP was slightly shorter in Group 2. Intubation conditions were always optimal except for one patient of Group 1. DISCUSSION: Both induction techniques achieve good intubating conditions. Possible explanations for the between-group BIS difference include variable appreciation of the CCSP endpoint, different induction lengths or sevoflurane equilibration times, or sevoflurane-induced increase in electroencephalogram power. A better indicator of the best time to intubate is needed to avoid too deep anesthesia in children.

[Rapid opiate detoxification under anesthesia (RODA)]. / Sevrage rapide aux opiacés sous anesthésie (RODA).

Rapid Opiate Detoxification under Anesthesia (RODA) involves the use of opiate antagonists combined with anesthesia and pharmacotherapy to reduce withdrawal symptoms. The aim of our study was to measure the plasma concentrations of heroin metabolites and methadone during anesthesia and patient stay at the hospital in order to assess the amount of active substances at each protocol step. Plasma concentrations of antagonists were also quantified and compared to the recommended target values. Blood samples were drawn in 10 patients undergoing RODA at different times of the procedure (during anesthesia, in post-anesthesia care unit and in psychiatry unit). The plasma concentrations of heroin metabolites, methadone and antagonists were measured using a previously described method. Heroin active metabolites were no longer detected in the patient blood when helshe left the hospital; by contrast, methadone was still present at significant concentrations 3 days after the beginning of the detoxification procedure. Naltrexone analysis allowed us to adjust doses to insure opiate receptor blockade during acute withdrawal, which is a critical period.

[Pediatric anesthesia: little children, big problems]. / Anesthésie pédiatrique et hôpital de jour: les grands problèmes des petits enfants.

Infants and children are patients who are the most susceptible to benefit from a procedure in the ambulatory setting. However, some of these patients are at risk. They include infants, especially if premature, and children with sleep apnea syndrome or with current or recent upper respiratory infection. The present paper gives advices for an optimal anesthesic management of these young patients.

[Anesthesia and safety of procedures outside the operating room: "everyone's responsibility"]. / Anesthésie et sécurité des procédures en dehors du bloc opératoire: "l'affaire de tous".

Due to important technological improvements, anesthesiological activity outside the operating theatre is increasing. Most of these procedures are performed for gastroenterology procedures; other procedures include medical imaging, electroconvulsive therapy or cardioversion. The practice of anesthesia at alternative sites is associated with logistical difficulties with many constraints. Anesthesia will be requested if the procedure is likely to be unpleasant or painful, if the patient is not cooperative, or if the patient's hemodynamic condition is unstable. The pre-anesthesia assessment, an adequate monitoring and an appropriate choice of the anesthetic technique and drugs will be helpful in managing an anesthetic procedure too frequently neglected despite it is associated with risks similar to procedures performed in the operating theatre.

Comparison between two intraoperative intravenous loading doses of paracetamol on pain after minor hand surgery: two grams versus one gram.

BACKGROUND: Paracetamol (acetaminophen) is widely used for postoperative analgesia at a recommended dose of 1 g every six hours in adult patients. Increasing the loading dose to 2 g was suggested to improve immediate postoperative analgesia without increased toxicity in healthy adult patients. We tested the hypothesis that a loading dose of 2 g of intravenous paracetamol results in better postoperative analgesia after surgery as compared with a dose of 1 g. METHODS: Sixty adult patients scheduled for minor hand surgery under intravenous regional anaesthesia were randomized into two groups. The first group received 1 g of intravenous paracetamol before surgery while the second group received 2 g. Verbal numeric pain score, analgesic consumption, first night sleep quality, and patient's satisfaction were recorded during the first 24 hours. RESULTS: Verbal numeric pain scores during the first 24 hours after surgery were significantly lower in the 2 g paracetamol group as compared to the 1 g paracetamol group. No differences were found between the two groups with regard to rescue analgesic consumption, sleep quality and patient's satisfaction. CONCLUSIONS: An intraoperative loading dose of 2 g paracetamol improves postoperative analgesia after minor hand surgery as compared to 1 g paracetamol.

[Postoperative pain management in ambulatory pediatric surgery]. / Prise en charge de la douleur en pédiatrie après chirurgie ambulatoire.

Over the last fifteen years, child's pain has become one of our major concerns. In spite of this evolution, it remains one of the most frequent complications after ambulatory surgery. It is thus essential to implement all the resources we have at our disposal in order to optimize pain management. This can be obtained by basing our strategy on the concept of multimode analgesia. It is consequently essential that each team can achieve its own quality program; the corollary will be the development of clear recommendations for the parents with a systematic analgesics regulation at home and the possibility to resort to the family doctor or to the ambulatory centre in the event of persistence of pain.

Changes in blood glucose and plasma insulin levels induced by bradykinin in anaesthetized rats.

1. The influence of bradykinin (BK) on blood glucose and plasma insulin levels was investigated in anaesthetized rats. 2. Blood glucose level was dose-dependently increased by intravenous infusion of BK. This effect of BK was enhanced by captopril, an inhibitor of angiotensin-converting enzyme (ACE). Des-Arg9-bradykinin (DABK), a kinin B1 receptor agonist, did not modify blood glucose levels while the effect of BK was inhibited by Hoe-140, a kinin B2 receptor antagonist. 3. The effect of BK was reduced by the NO-synthase inhibitor, N(omega)-nitro-L-arginine methyl ester (L-NAME), and by the cyclo-oxygenase inhibitor, indomethacin. The effect of BK was suppressed by the association of propranolol with phentolamine or phenoxybenzamine. It was also reduced by hexamethonium, a ganglion-blocking drug. In adrenalectomized rats, the infusion of BK slightly decreased blood glucose levels. 4. The hyperglycaemic effect of adrenaline was suppressed by propranolol associated with phentolamine or phenoxybenzamine, but it was not modified by L-NAME. 5. Infusion of BK did not modify plasma insulin levels. However, after phentolamine and propranolol, BK induced a transient 2 fold rise in plasma insulin levels. The release of insulin was dose-dependent and inhibited by Hoe-140. 6. We conclude that infusion of BK induces, via a stimulation of B2 receptors, the release of NO and of prostanoids. The latter agents activate through a reflex pathway the release of catecholamines from the adrenal medulla. This release increases blood glucose levels and reduces plasma insulin levels. After adrenoceptor inhibition, BK induces a secretion of insulin, via the stimulation of B2 receptors.

Pitfalls in the management of a child with mild haemophilia A and a traumatic hyphaema.

A 12-year-old boy presented with a traumatic hyphaema that failed to settle with the standard treatment. Subsequent investigation showed that despite a normal APTT, he had a low factor VIII:C. Treatment with DDAVP precipitated further bleeding despite correction of the fVIII:C to normal, possibly caused by the vasodilation induced by the therapy. Bleeding was effectively treated with recombinant fVIII concentrate. DDAVP may be contraindicated in mild Haemophilia and von Willebrand patients for treatment of traumatic hyphaema.

Pragmatism and Project 2000: the relevance of Dewey's theory of experimentalism to nursing education.

In this paper, the author focuses upon one of the most influential educational theories of the 20th century: the experimentalism of John Dewey. Based on the pragmatic philosophy of Charles Peirce and William James, experimentalism proposed that children learned by observing the consequences of their actions, such that learning became a continuous 'transaction' between learner and environment. This paper traces the main features of experimentalism, examining its emphases on focus, on action and transaction and on projection. It argues that the designers of Project 2000 curricula in Britain have neglected the insights Dewey provided into the relationships between experience and learning. Drawing briefly on research undertaken by the author into the provision of learning experiences in the community for Project 2000 students, this paper proposes that there is a need to provide Project 2000 students with learning experiences which will permit them to project their ideas and learn from the consequences of their actions.

Evaluation of screening for oral cancer and precancer in a company headquarters.

Oral cancer and precancer appear to fulfil many of the criteria for a disease suitable for mass screening. Several commercial organisations in the UK have introduced screening for their employees. One program has been formally evaluated over the course of 1 yr. Of 553 company headquarters staff aged > or = 40 yr, 292 (53%) responded to the well-publicised screening invitation and received a simple clinical examination of the oral mucosa from one of two company dentists. In addition, 17 staff were screened from a separate company work-site. After screening, subjects were examined independently by an oral medicine specialist with access to the relevant diagnostic aids. The dentists' screening decisions were validated against the specialist's definitive diagnoses (the 'gold standard'). The true prevalence of subjects with lesions diagnosed as positive (white patch, red patch or ulcer of greater than 2 weeks' duration) was 17 (5.5%). Overall, sensitivity was 0.71 and specificity, 0.99. The compliance rate to screening among headquarters subjects in seven occupational categories did not differ significantly from the occupational profile for all headquarters personnel. Estimates of relative risk of a positive diagnosis were calculated by logistic regression for five independent variables; gender, age, moderate smoking, heavy smoking, and smoking combined with greater than low risk alcohol consumption. Only heavy smoking (> or = 20 cigarettes per day) produced a significant odds ratio (3.43, P < 0.05).

A report on misonidazole in randomized trial in locally advanced head and neck cancer.

A prospective randomized trial is reported involving 97 patients with locally advanced cancer of the head and neck. Using six large fractions of radiation (3600 rad in 17 days) the addition of misonidazole (2.0gm per m2 body surface) with each fraction did not increase the local control rate at one year. It is thought that this is probably because of an inadequate tumor concentration of the drug.