Prospective validation of a new airway management algorithm and predictive features of intubation difficulty.

BACKGROUND: Some patients have features that indicate possible difficulty with direct laryngoscopy for tracheal intubation. Prediction of the likely outcome and selection of patients for an enhanced management algorithm would reduce the possible harm from failed intubation attempts. METHODS: Adult elective patients were assessed for seven features associated with difficult direct laryngoscopy, ranked in difficulty from 0 to 3. For a patient with at least one Class 3 feature, or two or more features of class 1 or higher, the enhanced management used a channelled videolaryngoscope Airtraq™ instead of a Macintosh laryngoscope. A long flexible angulated stylet and a flexible fibrescope would be used as the second and third steps. For patients with lesser difficulty scores, a Macintosh laryngoscope was used. Outcomes of enhanced management were analysed. Logistic regression and Random Forest algorithm, using the ranks of the predictive features, were used to predict difficulty during enhanced management. RESULTS: We prospectively studied 16 695 patients. We selected 1501 (9%) for enhanced management, and tracheal intubation was successful in all of them. Of these, 73% were intubated in less than 30 s, and only 4.5% required more than 4 min for intubation. Progression to the second and third steps of enhanced management was predicted by restriction of mouth opening and reduced cervical spine mobility. CONCLUSIONS: An enhanced management algorithm allowed successful tracheal intubation of all patients with anticipated difficult laryngoscopy. The need to combine the use of a stylet and a fibrescope with the Airtraq™ could be predicted with a high degree of certainty.

[Epidemiology of the medico-legal risk associated with the practice of ambulatory surgery in France: a study based on insurance data]. / Épidémiologie du risque médico-légal lié à la pratique de la chirurgie ambulatoire en France: données SHAM.

UNLABELLED: The medico-legal risk specifically associated with the practice of ambulatory surgery is still not well studied. SHAM insurances are the biggest French provider of medical liability insurances. The study of the insurance claims provided by this insurer is therefore a relevant source of data on the complications related to ambulatory surgery. OBJECTIVE: The aim of this study was to compare the claim rate related to ambulatory surgery with non-ambulatory surgery. STUDY DESIGN: We did a retrospective study on insurance claims provided by SHAM insurances between 2007 and 2011 to compare the claim rate related to ambulatory surgery with non-ambulatory surgery. MATERIALS AND METHODS: We searched the files in the SHAM database, and then analyzed them. RESULTS: On the study period, out of a total of 29565 registered claims, 467 (1.6%) originated from ambulatory surgery. On the total of 29,098 registered claims for non-ambulatory surgery, 2151 (7.4%) led to a condemnation whereas the rate was 7% (33 out of 467 claims) for ambulatory surgery. The condemnations linked to ambulatory surgery amounted to 1.5% of the total (33 out of 2184), for a cost of 1.7 M€ (versus 400,3 M€ for non-ambulatory surgery). The average cost of a compensation is therefore 50,500 € for ambulatory surgery and 186,000 € for non-ambulatory surgery. The medical specialties concerned are primarily ophthalmology, abdominal and orthopedics surgery. The main identified causes were medical errors (n=16) and nosocomial infections (n=13). CONCLUSIONS: The claim rate in ambulatory surgery is proportionally less frequent with compensations three times less and were related to the most frequent type of surgery done in ambulatory settings. These data should help strengthen quality approach in ambulatory surgery.

[Faulty implants: the court of appeal has ruled surgeon's responsibility]. / Prothèse défectueuse : la responsabilité du chirurgien écartée par la Cour de cassation.

It is in this atmosphere fuelled by the recent scandal of the PIP implants that the final court of appeal has given a judgment on July 12, 2012 which reorients the debate. While patients seeked a shared responsibility between the provider of the implants and the surgeon, in this case of faulty testicular implants, the final court of appeal just ruled out the responsibility of the surgeon. But this jurisprudence can only be applied to private law, i.e. for private healthcare whereas lawsuits filed against public hospitals depend on a different legal liability system.

Evaluation of serum procalcitonin concentration in the ICU following severe burn.

The goal of the study was to analyse plasma procalcitonin (PCT) concentrations during infectious events of burns in ICU. Clinical and laboratory data were collected at admission and twice a week in burned patients admitted with a total body surface area (TBSA) >20%. Procalcitonin was determined using both a semi-quantitative detection (PCT-Q) and a quantitative immunoluminometric method (PCT-Lumi). A total of 359 time points in 25 consecutive patients with 40+/-17% (20-86%) TBSA burned, defined as a procalcitonin concentration associated with an inflammatory status according to society critical care medicine definition, were made. The principal site of infection was the respiratory tract (84% of patients required mechanical ventilation). PCT-Lumi values corresponded to the four semi-quantitative ranges of PCT-Q and statistically reflected the simultaneously observed inflammatory status (Kruskall-Wallis test). The area under the receiver operating characteristic curve for C-reactive protein (CRP) was higher than those for PCT and white blood cell (WBC) count, but this difference was not significant. The optimum PCT cut-off value was 0.534 ng/ml with sensitivity and specificity of 42.4% and 88.8%, respectively. However, PCT does not appear to be superior to C-reactive protein (CRP) and white blood count (WBC) as diagnosis marker of sepsis in burns. PCT is not sufficient to diagnose and to follow infection in burns admitted in ICU.

Difficult intubation in thyroid surgery: myth or reality?

Thyroid surgery is considered to be a risk factor for difficult airway management. We prospectively studied 324 consecutive patients undergoing thyroid surgery to investigate the incidence of difficult intubation as evaluated by the intubation difficulty scale as well as other specific predictive factors. The overall incidence of difficult intubation was 11.1% (95% CI: 7.6-14.5). Median intubation difficulty scale was 0 (25th-75th percentile: 0; 2.7). In three predefined groups (no echographic goiter, clinically palpable goiter, and impalpable goiter), difficult intubation occurred in 10% (95% CI: 4.8-17.4), 13% (95% CI: 6.5-18.4), and 11% (95% CI: 4.7-16.8) of patients, respectively, with no statistical difference among the groups. Specific predictive criteria (palpable goiter, endothoracic goiter, airway deformation, airway compression, or thyroid malignancy) were not associated with an increased rate of difficult intubation. Classical predictive criteria (mouth opening <35 mm, Mallampati III or IV, short neck, neck mobility <80 degrees , thyromental distance <65 mm, and a retrognathic mandible) were significantly reliable in the univariate analysis as risk factors for difficult intubation.

Postoperative residual neuromuscular block: a survey of management.

BACKGROUND: To avoid postoperative residual neuromuscular block there is a need for a change in clinician's attitude towards monitoring and reversal. This study aims to evaluate changes of perioperative neuromuscular block management during the last decade in our institution and to quantify the incidence of postoperative residual neuromuscular block. METHODS: Patients receiving intermediate-acting neuromuscular blocking agents for scheduled surgical procedures during 3-month periods in 1995 (n=435), 2000 (n=130), 2002 (n=101), and in 2004 (n=218) were prospectively and successively enrolled in our study. The management of neuromuscular block in the operating room and the adequacy of the recovery were at the discretion of the anaesthesiologist. An attempt was made between each study period to promote a change in the management of neuromuscular block. In the post-anaesthesia care unit, train-of-four (TOF) stimulations were used to assess the presence of a residual neuromuscular block. RESULTS: Between 1995 and 2004 quantitative measurement and reversal of neuromuscular block in the operating room increased from 2 to 60% and from 6 to 42%, respectively (P<0.001). During the same time, the incidence of residual neuromuscular block defined as a TOF ratio less than 0.9 decreased from 62 to 3% (P<0.001). Use of objective neuromuscular monitoring and/or anticholinesterase drugs was less likely in patients with an inadequate recovery (P<0.001). CONCLUSIONS: During the last decade the incidence of residual neuromuscular block strongly decreased in our institution. It confirms the positive impact of neuromuscular monitoring and reversal of neuromuscular block in routine anaesthetic practice.

[Evaluation of a medical equipment checklist before intensive care room opening]. / Evaluation d'une liste de contrôle du matériel médical avant ouverture de chambre en réanimation.

OBJECTIVE: To describe and to assess the effectiveness of a checklist concerning the intensive care rooms' equipment before patients' admission. STUDY DESIGN: A 4 years prospective study with 3 successive assessments. METHODS: Medical equipment inspection of 20 intensive care unit (ICU) rooms was first checked without using a written checklist (phase I). A written procedure called "room opening checklist" (ROC) was instituted to inspect medical equipment, and then assessment of its use and effectiveness was performed 2 years (phase II) and 4 years later (phase III). RESULTS: Phase I (1998): medical equipment of 20 intensive care rooms was inspected before patients' admission. None of the 20 intensive care rooms was strictly equipped in accordance with the unit's official procedure. Phase II (2000): ROC has been used for all the 20 evaluated ICU rooms, 17 ICU rooms were equipped in accordance with the official procedure. Phase III (2002): ROC has been used for 19 ICU rooms, 18 ICU rooms were correctly equipped. CONCLUSION: The routine use of ROC has improved the adequacy of the ICU room's equipment endowment in our intensive care units.