Strategy to secure the neuraxial route in anaesthesia: Risk mapping and feedback from the application of the ISO 80369-6 standard NRFit® connectors.

INTRODUCTION: In anesthesia, a medication error would occur every 20 to 133 anesthesia procedures, and 14% is related to a route administration error. To secure neuraxial route, ISO group published a norm in 2016 to develop specific connectors, the "NRFit® connector". The main objective of this work, is to develop a risk mapping related to neuraxial medication errors therefore prepare the NRFit® implementation in anesthesia units in a French Universitary Hospital. METHODS: Failure modes, effects and criticality analysis (FMECA) methodology was used for our risk mapping which was divided in 3 anesthesia specialities. For each, the analysis was performed for accidental neuraxial administration of intravenous drugs, and its opposite error. Secondly, NRFit® devices were tested for 1 month by 3 experimented anesthetists. RESULTS: The majority of reported errors concerns epidural and intrathecal anesthesia, and more frequently in the field of obstetrics. Opioids and tranexamic acid, administered in neuraxial route, are drugs with the highest criticality. The tests were rather conclusive and made it possible to highlight the additional needs in medical devices. DISCUSSION: Obstetrics is the riskiest area due to the frequency of epidural anesthesia, the administration of critical drugs in intravenous and neuraxial route. This work increased the awareness of our group, improved the measure of this risk and harmonized practices. CONCLUSION: This work is the first step of the project to prevent administration route error in anesthesia during patient's drug management. The next step will be the NRFit® implementation for epidural and combined spinal-epidural anesthesia in our hospital.

Day case laparoscopic nephrectomy with vaginal extraction: initial experience.

OBJECTIVE: To assess the feasibility of laparoscopic nephrectomy with vaginal extraction in an ambulatory setting. METHODS: Two patients underwent a laparoscopic (1 was robot assisted) nephrectomy with vaginal extraction for a nonfunctioning kidney in an ambulatory setting. Both interventions were performed by the same surgical team comprising a urologic surgeon and a gynecologic surgeon. The operative specimen was vaginally extracted via an incision in the posterior fornix at the end of the intervention. Patients had to respect very strict socioenvironmental and clinical criteria. Anesthesia was achieved using short-acting agents. Only first- and second-step analgesics were used (morphine-free protocol). The main judgment criteria were visual analog scale assessment for postoperative pain, the Clavien-Dindo classification for surgical complications, and the hospital readmission rate. RESULTS: Two female patients (37 and 41 years old) have been successfully operated with this technique. No major perioperative or postoperative complications (Clavien-Dindo grade >2) were reported, and no patient readmission was required. Postoperative pain was well managed with visual analog scale scores ≤ 5. Both patients operated in the ambulatory setting had Chung scores of 10 before their discharge. CONCLUSION: Laparoscopic or robotic nephrectomy with vaginal extraction can be performed in an ambulatory setting in carefully selected patients. The association of fast-track surgical techniques and vaginal extraction by eliminating the abdominal wound extraction source of postoperative pain allows performing this operation in this setting with a high level of satisfaction.