[Morbidity and mortality conferences in anaesthesia and intensive care: experience feedback from Nancy university hospital]. / Revues de morbi-mortalité (RMM) en anesthésie-réanimation : retour d'expérience au CHU de Nancy.

OBJECTIVES: Assessment of the morbidity mortality conferences (MMC) durableness in the Anaesthesiology and Surgical Intensive Care Department of the Urban Hospitals of Nancy University Hospital; evaluation of the proportion of medical education in the corrective actions implemented, and research for improvement ways. PATIENTS: All the cases of death and near-death in the operating room and all the cases deemed to be instructive or useful for security improvement. METHOD: Retrospective analysis of MMC activity since its initiation in 2005. RESULTS: Durability of MMC and good attendance rate have been sustained over time. As in the USA, MMCs result firstly in resident's education and continued medical education actions. Medical education actions represent 75% of all corrective measures, followed by changes in practices (62%), in procedures (48%) and in organisation (5%). DISCUSSION: The development process of a culture of the safety has been initiated and perpetuated. Some ways of improvement have been proposed: MMC must certainly be widened as well regarding to the categories of addressees, as the topics (any event deemed to be noteworthy for the safety of care) or the time scale of the analysis. Others propositions: preparation of the presentations with a colleague experienced in MMC; participation of external MMC experts; monitoring of local markers of security of care and of corrective measures efficiency; inclusion of MMC cases presentation in the trainees pedagogic objectives.

Pre-existing arterial stiffness can predict hypotension during induction of anaesthesia in the elderly.

BACKGROUND: The aim of the present study was to establish whether elevated carotid-femoral pulse wave velocity (c-fPWV), an indicator of aortic stiffness, assessed before surgery, is correlated with variations in arterial pressure (AP) during induction of anaesthesia in elderly patients undergoing non-cardiovascular surgery. METHODS: c-fPWV was measured with the PulsePen(®) device during pre-surgical anaesthetic evaluation. Monitoring included electrocardiography, pulse oximetry, non-invasive AP, heart rate, bispectral index (BIS), and oxygen concentration during induction of anaesthesia with propofol and remifentanil. Anaesthesia was induced so as to maintain BIS values between 40 and 50. RESULTS: Forty-five patients, aged [mean (sd)] 71.1 (5.8) yr, were studied. The mean value of c-fPWV was 12.1 (3.9) m s⁻¹. There was no correlation between hypotension during anaesthesia induction and total dosage or rate of administration of propofol or remifentanil. In univariate analysis, only age and PWV significantly correlated with the decreases in AP, and the association between c-fPWV and a decrease in AP was also seen in multivariate analysis (r = 0.36, P< 0.05). Patients classified as having 'high stiffness' (c-fPWV ≥ 12.9 m s⁻¹) had 25% further decrease in systolic AP during anaesthesia induction than those with lower PWV [75.2 (5.7) vs 60.2 (4.2) mm Hg, P < 0.05]. CONCLUSIONS: Increased aortic stiffness, as assessed by PWV measured during preoperative anaesthetic evaluation, is associated with more pronounced hypotension during induction of anaesthesia. Measurement of aortic stiffness in the elderly may thus represent a valid indicator of the risk of hypotension during anaesthesia induction.

[Interest of evaluation of professional practice for the improvement of the management of postoperative pain with patient controlled analgesia (PCA)]. / Intérêt de l'EPP pour l'amélioration de la prise en charge de la douleur postopératoire par analgésie contrôlée par le patient (ACP).

OBJECTIVES: To evaluate the daily practice of postoperative PCA in Nancy University Hospital, in continuity with a quality program of postoperative pain (POP) care conducted in 2003. TYPE OF STUDY: A retrospective audit of patient medical records. MATERIAL AND METHODS: A review of all the medical records of consecutive surgical patients managed by PCA over a 5-week period in six surgical services. Criteria studied: Evaluation of hospital means (eight criteria) and of medical and nursing staff practice (16 criteria). A second audit was conducted 6 months after the implementation of quality improvement measures. RESULTS: Assessment of the hospital means: temperature chart including pain scores and PCA drug consumption, patient information leaflet, PCA protocol, postoperative pre-filled prescription form (PFPF) for post-anaesthesia care including PCA, and optional training of nurses in postoperative pain management. EVALUATION OF PRACTICES: One hundred and fifty-nine files of a total of 176 patients were analyzed (88%). Improvements noted after 6 months: trace of POP evaluation progressed from 73 to 87%, advance prescription of PCA adjustment increased from 56 to 68% and of the treatment of adverse effects from 54 to 68%, trace of PCA adaptation by attending nurse from 15 to 43%, trace of the administration of the treatment of adverse effects by attending nurse from 24% to 64%, as did the use of PFPF from 59 to 70%. CONCLUSIONS: The usefulness of a pre-filled prescription form for post-anaesthesia care including PCA prescription is demonstrated. Quality improvement measures include: poster information and pocket guides on PCA for nurses, training of 3 nurses per service to act as "PCA advisers" who will in turn train their ward colleagues in PCA management and the use of equipment until an acute pain team is established.