[Short version of recommendations for enhanced recovery program (ERP) for cystectomy: Technical measures]. / Version courte des recommandations de la récupération ameliorée après chirurgie (RAAC) pour la cystectomie : mesures techniques.

INTRODUCTION: The enhanced recovery program (ERP) is a management mode whose objective is to reduce the risk of complications and allow the patient to recover more quickly all its functional capacities and to reintegrate at most quickly and safely in his usual environment. This intentionally synthetic document aims to disseminate in the urological community the main points of the ERP recommendations for cystectomy. This work, coordinated by AFU, involves several other partners. The full document is available on the "Urofrance" website. Another article will follow on organizational measures. METHOD: The development of the recommendations is based on the method "formalized consensus of experts" proposed by the HAS. The report is based on a systematic review of the literature (January 2006-May 2017), two rounds of iterative quotations and a national proofreading. Levels of proof of conclusions and gradation of recommendations are based on the HAS grid. RESULTS: The bibliographic strategy made it possible to retain 298 articles. Only the recommendations that obtained a strong agreement after the two rounds of iterative listing were retained. The recommendations presented here are in chronological form (before, during, after hospitalization). Twenty-six key points on the technical and organizational measures of ERP have been identified. CONCLUSION: The result of the literature review, supplemented by expert opinion, suggests a significant clinical interest in the application and dissemination of ERP for cystectomy, despite the limited data available for this indication.

Infection risk and cost-effectiveness of commercial bags or glass bottles for total parenteral nutrition.

OBJECTIVE: To determine whether the greater daily expense of administering total parenteral nutrition (TPN) via plastic bags changed once daily, compared to glass bottles changed thrice daily, could be offset by savings from a reduction in nosocomial infections. DESIGN: The costs and potential benefits of commercially available TPN bags and TPN in glass containers were compared. Costs were computed from the viewpoint of the hospital, first in a general model and then for two specific examples, Crohn's disease and intensive-care unit (ICU) patients. The extra cost of using bags was $20 per day. The total cost of nosocomial bacteremia was estimated at $6,000. The monetary benefits of using TPN bags were $6,000XT, where XT was the percentage of nosocomial infections averted. We also considered that reduction in intravenous (IV)-line manipulation could reduce bacteremia-related mortality and computed a cost-per-life-saved ratio. RESULTS: Modeling showed that TPN in bags could yield a net benefit when the absolute reduction in the daily risk of nosocomial bacteremia reached the threshold value of 0.3%. Such a reduction could not be attained in patients with Crohn's disease, and corresponded to a 50% to 60% reduction of infection rates in ICU patients. Varying the risk of mortality attributable to IV-line-related infection from 1% to 13% resulted in a cost effectiveness of using TPN bags ranging from $90,000 to $7,000 per life saved in ICU, assuming a two-thirds reduction in IV-line infections, and from $180,000 to $14,000 if the infection rate was reduced by one third. CONCLUSION: The baseline cost-minimization analysis concluded that the extra cost of TPN bags was not justified by the extra savings. The cost-effectiveness analysis, however, found that the cost per life saved fell within the accepted range of public health interventions, provided a large fraction of infections are averted using TPN bags.

Bilateral massive adrenal haemorrhage complicating anaphylactic shock: a case report.

A case of bilateral adrenal haemorrhage complicating anaphylactic shock is reported. Hypovolemic shock related to peritoneal haemorrhage was the main feature landing to laparotomy. Ultrasonographic examination was not contributive, but CT scan easily documented the adrenal haemorrhage and must be considered a valuable diagnostic tool when adrenal haemorrhage is suspected.

[Patient-controlled analgesia: effect of adding continuous infusion of morphine]. / Analgésie contrôlée par le patient: effet de l'adjonction d'une perfusion continue de morphine.

This double blind study aimed to assess the effects of a continuous intravenous (i.v.) infusion of morphine added to an intermittent bolus patient controlled analgesia on morphine demand and related side-effects. Patients scheduled for abdominal and thoracic surgery (ASA 2 or 3) were randomly allocated postoperatively to three groups (n = 10 each): group 1 were given i.v. boluses of 2 mg of morphine (lockout interval = 15 min); the other two groups were given the same boluses as well as a continuous i.v. infusion of either 1 mg.kg-1 of morphine (group 2) or 2 mg.kg-1 (group 3). Pain was assessed with a visual analog scale before starting analgesia, and after 1, 2, 3, 4, 8, 16, 24 and 36 h. Total and bolus morphine doses were recorded at the same time. Breathing rate and the level of sedation were measured every hour and blood gases every time 40 mg of morphine had been consumed. Morphine administration was stopped if breathing rate decreased to less than 10 c.min-1, the patient became too sedated, or PaCO2 rose to more than 45 mmHg. Pain scores were similar in the three groups. Total amounts of morphine were higher in groups 2 (56.8 +/- 23.8 mg) and 3 (116.2 +/- 41.8 mg) compared with group 1 (38.2 +/- 17.8 mg) (p < 0.05). Morphine administration was stopped in 5 patients in group 3 and in 1 in group 2 because PaCO2 had risen to more than 45 mmHg. Therefore, a continuous i.v. infusion is not required in patients receiving PCA, all the more so as this has deleterious respiratory effects.

[Analysis of failures of spinal anesthesia as a function of practice development in a university hospital]. / Analyse des échecs de la rachianesthésie en fonction de l'évolution de la pratique d'un hôpital universitaire.

This study is a retrospective analysis of 303 consecutive spinal anaesthesia performed in orthopaedic patients of a University Hospital between January and December 1990. Failure of spinal anaesthesia was defined as the requirement for general anaesthesia to perform surgery. The parameters studied as possible risk factors of failure were patients demographics, local anaesthetic agents and solutions and techniques of spinal anaesthesia (single injection versus continuous spinal anaesthesia). Failures were related to inadequate or incomplete extension of sensory blockade or to difficulties to perform spinal injection. Continuous spinal anaesthesia was performed in 209 patients mostly with 0.5% isobaric bupivacaine, while 94 patients received a single injection of either hyperbaric 0.5% tetracaine with adrenaline or 0.5% bupivacaine or 5% lidocaine. Failures occurred in 6.3% of the cases but were significantly less frequent with continuous spinal anaesthesia (4.8%) than with the conventional technique (9.6%). The incidence of failure was higher with hyperbaric tetracaine (11.1%) confirming its poor reliability. Inadequate extension of the anaesthetic block was the main cause of failure whatever the spinal anaesthetic technique. These results point out the reliability of continuous spinal anaesthesia but problems may occasionally occur due to spinal catheter misplacement.

[Pharmacology and mechanism of action of opiates administered by the subarachnoid route]. / Pharmacologie et mode d'action des opiacés administrés par voie sous-arachnoïdienne.

The sites of action of spinally administered opiates are specific receptors (mu kappa delta) located in the spinal dorsal horn. Pharmacokinetics of spinally administered opiates are determined by their lipophilic property. Morphine has a weak octanol-water partition coefficient and remains in the CSF during a long period following the cephalic movements of lumbar CSF to the supraspinal structures. More lipophilic opiates are rapidly eliminated from the CSF. Nevertheless, significant pethidine concentrations are documented in the ventricular CSF, due to vascular absorption of the drug. Pharmacokinetics features of different opiates determine the duration of analgesia and the risk of respiratory depression after spinal injection.

[Arthroscopic shoulder surgery and ischemic cerebral complications]. / Chirurgie arthroscopique de l'épaule et complications ischémiques cérébrales.

The authors report three cases in which cerebral ischemia occurred during arthroscopic shoulder surgery performed in beach chair position under general anaesthesia and interscalene plexus block. Several similar cases have been published in the literature. This rare but extremely severe complication is related to the decrease in cerebral perfusion pressure (CPP). Monitoring of CPP in the beach chair position using the measurement of arterial pressure and taking into account the hydrostatic gradient is essential. Prevention includes correction of preoperative hypovolaemia, treatment of postural arterial hypotension, adequate installation of the patient's head, aggressive treatment of perioperative arterial hypotension (whatever the cause) and avoidance of deliberate perioperative arterial hypotension. Routine use of non-invasive monitoring of cerebral oxygenation has been advocated to avoid this accident but its usefulness has to be confirmed by clinical studies.