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Introduction: Preanesthesia teleconsultation helps reduce availability constraints as well as direct and indirect expenses. The TELECAM trial was performed to assess the quality of preanesthesia teleconsultation in terms of clinical parameters evaluation, feasibility, patient satisfaction and preoperative anxiety, and anesthesiologist satisfaction. Methods: TELECAM was an investigator-initiated, prospective, single-center, randomized, controlled, parallel group, evaluator-blinded, open-label study. Patients with a scheduled ambulatory surgery (orthopedic or hand surgery) were randomized into the in-person preanesthesia consultation group or the preanesthesia teleconsultation (conducted at the patient's home or workplace) group. The quality of the teleconsultation was evaluated through agreement on intubation difficulty, predictable mask ventilation difficulty, and American Society of Anesthesiologists (ASA) scores between the preanesthesia consultation and the preanesthesia in-person visit. Results: A total of 241 patients were included, and 208 were considered in the analyses. The feasibility of teleconsultation was high, with a feasibility ratio of 87.5%. The quality of the preanesthesia consultation regarding the evaluation of predictable intubation, mask ventilation difficulties, and ASA score, did not differ between the two groups (p = 0.23, 0.29, and 0.06, respectively). The preoperative satisfaction was higher for patients who had a preanesthesia teleconsultation (p = 0.04). Patients' preoperative anxiety did not differ between the two groups (p = 0.90). The median satisfaction of the anesthesiologists who performed the teleconsultation reached a maximum of 10 (IQR: 8.0; 10.0). Conclusion: This study showed positive results for the quality of preanesthesia teleconsultation on the evaluation of clinical parameters, with high feasibility and satisfaction of the patients and anesthesiologists. The trial was registered in ClinicalTrials (NCT03470896).
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Satisfação do Paciente , Consulta Remota , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Adulto , Idoso , Cuidados Pré-Operatórios/métodos , Ansiedade , Anestesia/métodos , Anestesia/normas , Procedimentos Cirúrgicos Ambulatórios/métodos , Estudos de ViabilidadeRESUMO
STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT02279628); registered 31 October 2014.
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Analgesia , Morfina , Analgésicos Opioides , Anestésicos Locais , Feminino , Humanos , Injeções Espinhais , Medição da Dor , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , GravidezRESUMO
BACKGROUND: Analysis of pupillary reflex dilation (PRD) assesses the balance of nociception--antinociception. Laparoscopic surgery induces haemodynamic variations that are misleading. During laparoscopy, PRD guidance helps differentiate haemodynamic changes because of excess nociception from secondary changes related to the reflex release of endocrine factors. OBJECTIVE: The present study evaluated the effect of PRD-guided antinociception on the administration of intra-operative remifentanil and immediate postoperative morphine consumption in patients undergoing elective laparoscopic surgery. DESIGN: The study was a single-blind, randomised controlled trial. SETTING: The study took place at two sites at the University Hospital of Nancy from March 2014 to November 2017. PATIENTS: A total of 100 patients who underwent scheduled laparoscopic surgery were included. INTERVENTIONS: Patients were randomly given remifentanil guided by PRD (PRD-guided) or standard anaesthesia care (control). MAIN OUTCOME MEASURES: The primary outcome was intra-operative remifentanil consumption. Secondary outcomes included morphine consumption in the immediate postoperative period and the number of intra-operative haemodynamic events. RESULTS: Data from 95 patients were analysed. Intraoperative remifentanil consumption was lower in the PRD-guided group than in the control group: median [IQR], 0.09 [0.07 to 0.11] vs. 0.14 [0.12 to 0.16] µgâkg-1âmin-1, with a mean difference (95% confidence Interval, CI) of 0.048 (0.035 to 0.060) µgâkg-1âmin-1; Pâ<â0.0001. Morphine consumption was 0.13 [0.1 to 0.5] vs. 0.15 [0.11 to 0.4] mgâkg-1 (Pâ =â0.52) in the PRD-guided and control groups, respectively. The number of hypertensive and tachycardia events was greater in the PRD-guided group than in the control group: Hypertensive events 60.4% vs. 32.6%, relative risk 1.85 (95% CI, 1.24 to 2.84), Pâ=â0.004; tachycardia events 31.6% vs. 4.3%, relative risk 2.09 (95% CI, 1.45 to 2.84), Pâ<â0.001. CONCLUSIONS: When PRD is used to differentiate between haemodynamic events arising from noxious stimuli and those events because of other nonsurgical stimuli, then intra-operative remifentanil administration is reduced intra-operatively during laparoscopic surgery but there was no change in postoperative morphine consumption. TRIAL REGISTRATION: Clinicaltrials.gov NCT02116868.
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Analgésicos Opioides , Laparoscopia , Dilatação , Método Duplo-Cego , Humanos , Morfina , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/prevenção & controle , Reflexo Pupilar , Remifentanil , Método Simples-CegoRESUMO
Cuff pressure gauges are the only recommended instrument to perform controls on endotracheal tube cuff pressure during anesthesia. No calibration is mandatory for these devices. The aim of this study was to describe the level of conformity of various cuff pressure gauges. The single-center measurements were performed with a cuff pressure calibrator on all cuff pressure gauges that were usually used in the operating room. Seven measurements (repeat three times) on each cuff pressure gauges at different levels of pressures (i.e. 0, 10, 20, 27, 30, 40 and 50 cmH2O) were performed. Our homologation criteria were either the reliability of the leak test (value of cuff pressure gauges maintained at 120 cmH2O during 5 s) or the difference between the values of the cuff pressure tested and the calibrator below 1.3 cmH2O at the range of 20-30 cmH2O. A total of 567 measurements on 27 cuff pressure gauges were performed. Only 30% (n = 8/27) of the cuff pressure gauges reach our homologation criteria. 30% (n = 8/27) failed at the leak test. 48% (n = 13/27) of the cuff pressure gauges tested, had a calibration variation error > 1.3 cmH2O on the levels of pressure between 20 and 30 cmH2O. A minority of cuff pressure gauges went through our homologation criteria. These results demonstrate us that there is a real problem of the reliability and the follow-up of those medical devices. This study suggests to reinforce biomedical engineering control on these devices.
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Intubação Intratraqueal/instrumentação , Manometria/instrumentação , Manometria/normas , Anestesia , Calibragem , Desenho de Equipamento , Humanos , Salas Cirúrgicas , Pressão , Reprodutibilidade dos Testes , Respiração , Traqueia/patologiaRESUMO
PURPOSE: Anesthesia is a medical specialty where a large number of technical skills need to be mastered with the learning curve for these skills depending on both the technique and the individual involved. The transversus abdominis plane (TAP) block has demonstrated its effectiveness especially in postoperative analgesia following midline laparotomy. It is usually described as a simple technique even though little is known about the learning curve for this block. The purpose of this study was to determine the learning curve for ultrasound-guided TAP block in anesthesiologists who had no prior experience performing the block. METHODS: This was a prospective observational study performed in gynecological and general surgery patients at the University Hospital Center of Nancy (France) between November 2011 and June 2012. After a short theoretical training, sixresidents were asked to perform, 20 TAP blocks under the supervision of a senior staff physician. The success of the procedure involved the visualization and identification of the different muscle planes, the peritoneum, the tip of the needle, an evaluation of the effectiveness of the block (sensory block), the absence of intervention from the supervisor, the absence of complications, less than three attempts, and a satisfaction score by the supervisor > 7 on a 0-10 rating scale. A learning curve/cummulative summation (LC-CUSUM) was generated. RESULTS: The six residents performed all 20 TAP blocks. All residents had already performed ultrasound-guided procedures. The procedure was considered mastered after performing 16 blocks on average for a 90% success rate. The average time (SD) to complete the block decreased from 6.8 (4.1 min) at the beginning to 2.8 (1.3) min at the end of the study. There was a decrease in the number of repositionings of the needle and in the number of interventions by the supervisor throughout the study. The LC-CUSUM analysis revealed that all residents had acquired the TAP block technique within 20 procedures. CONCLUSION: This study demonstrates that the TAP block can be rapidly mastered even if the learning curve varies due to inter-individual differences in dexterity and in the ease of obtaining the ultrasound images.
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Músculos Abdominais/inervação , Anestesiologia/educação , Internato e Residência , Bloqueio Nervoso/métodos , França , Hospitais Universitários , Humanos , Laparotomia/métodos , Curva de Aprendizado , Estudos Prospectivos , Fatores de Tempo , Ultrassonografia de IntervençãoRESUMO
OBJECTIVES: To determine the regional cerebral oxygen saturation of hemoglobin (rcSO2) in severe preeclamptic parturients exhibiting neurologic symptoms compared with healthy pregnant women (control) and to describe the effects of MgSO4 infusion on rcSO2 and cerebral and systemic hemodynamic variables. DESIGN: Prospective, observational study. SETTING: Obstetric critical care unit in a university-affiliated hospital. PATIENTS: Twenty severe preeclamptic parturients presenting with neurologic signs before any administration of MgSO4, and 20 control parturients. INTERVENTION: Infusion of MgSO4 in severe preeclamptic patients. MEASUREMENTS AND MAIN RESULTS: We measured rcSO2 using near-infrared spectroscopy, blood flow velocities of the middle cerebral artery, and cardiac output at baseline, 5 minutes, 1 hour, and 6 hours after the MgSO4 bolus (4 g), followed by continuous MgSO4 infusion (1 g/h). These measurements were also obtained in 20 control parturients at baseline and 6 hours. Baseline rcSO2 was significantly lower in the severe preeclamptic group: 61% (56-69) vs 66% (63-71) (p = 0.037). At inclusion, blood pressures were significantly higher in the severe preeclamptic group compared with the control group, whereas cardiac output and transcranial Doppler readings were similar. Five minutes after the MgSO4 bolus infusion, a median increase of 8.6% (3.2-18.1) in rcSO2 was observed (p = 0.007), reaching values of the control group that were maintained up to 6 hours. Blood pressures and systolic velocities of the middle cerebral artery significantly decreased (p < 0.01) after the MgSO4 bolus, whereas cardiac output did not change. The percentage increase in rcSO2 was negatively correlated to the mean blood pressure (r = 0.60, p < 0.0001). CONCLUSION: Cerebral oxygenation impairment can be detected by near-infrared spectroscopy monitoring in severe preeclamptic parturients. These results suggested the presence of disorders in cerebral microcirculation and/or changes in cerebral oxygenation. MgSO4 infusion in patients with severe preeclampsia restored rcSO2 to control levels with no systemic side effects. Further studies are needed to confirm the usefulness of near-infrared spectroscopy monitoring in patients with preeclampsia and to assess the action of other antihypertensive therapies on rcSO2.
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Circulação Cerebrovascular/fisiologia , Sulfato de Magnésio/administração & dosagem , Pré-Eclâmpsia/diagnóstico , Pré-Eclâmpsia/tratamento farmacológico , Resultado da Gravidez , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Adulto , Velocidade do Fluxo Sanguíneo , Débito Cardíaco/fisiologia , Estudos de Casos e Controles , Feminino , França , Idade Gestacional , Hospitais Universitários , Humanos , Infusões Intravenosas , Artéria Cerebral Média/diagnóstico por imagem , Monitorização Fisiológica/métodos , Oximetria/métodos , Paridade , Pré-Eclâmpsia/diagnóstico por imagem , Gravidez , Estudos Prospectivos , Valores de Referência , Índice de Gravidade de Doença , Ultrassonografia Doppler Transcraniana/métodos , Adulto JovemRESUMO
INTRODUCTION: Ultrasound-guided placement of Midlines catheters (MCs) is a standard procedure with many benefits for patients. Even if there are some guidelines worldwide, this invasive technique is still taught at the patient's bed and relies on mentoring in many care centers. The performance of this care by novice practitioners raises ethical and quality of care issues mainly because of its risk of complications. This study aimed to propose and assess a simulation-based learning method for the placement of MCs in novice practitioners. METHODS: A single-center prospective observational study was conducted with anesthesia residents who had no prior experience of Midline placement. Two workshops were planned. The first one consisted of a theoretical training and a simulated practical phase. The second workshop included an assessment of theoretical memorization, a practical exercise and adherence to the training program. RESULTS: The median score of the theoretical memorization was 14.6 (interquartile range [IQR]: 13.5-15.8). The MCs placement time was significantly higher (Med: 12.23 min; IQR: 12.21-12.80) for novice practitioners who did not successfully complete solo MCs placement in simulation versus novice practitioners who successfully completed solo MCs placement in simulation 6.66 min (IQR: 5.92-8.93) (p = 0.002). The number of attempts was significantly higher (p = 0.034) for the novice practitioners who did not successfully complete solo MCs placement in simulation with 67% having performed three punctures, against 0% for the novice practitioners who successfully completed solo MCs placement in simulation. All novice practitioners found this training model efficient for learning how to place MCs and considered it allows for reproducibility in care situations. CONCLUSION: This ultrasound-guided MCs training on simulation is an agile and fast alternative to traditional bedside training for anesthesia novice practitioners.
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INTRODUCTION: Ultrasound-guided placement of peripheral venous catheters requires appropriate equipment. Among the devices used, peripheral venous catheters have different structure and properties. This study aimed to define the impact of these different factors on the echogenicity of peripheral venous catheters. METHOD: An open comparative study was conducted from September 2022 to May 2023. Thirteen devices were introduced in a standardized manner along the longitudinal and transverse axes with the help of guides into a phantom at different angles. Two criteria defined the echogenicity of these devices: the surface occupied by the device in the image (composite criterion: length and diameter of the device and angle of insertion) and its brightness (average of the pixel intensity of gray). Sixty-five ultrasound images were recorded and postprocessed twice (blinded to the previous measurement) by an expert operator, for reproducibility purposes. RESULTS: The intra-observer reproducibility of all measurements was excellent, with an intra-class coefficient of >0.90 over the entire dataset. On the longitudinal axis, echogenicity was significantly influenced by insertion angle (p = 0.009), device length (p = 0.006), and the interaction of cannula component and insertion angle (p = 0.007). On the transverse axis, no factors significantly influenced the device's echogenicity. DISCUSSION: The echogenicity of a device is an essential component of successful ultrasound-guided peripheral venous catheter placement. Optimizing catheter intrinsic factors such as components of the cannula and length, and extrinsic factor like the insertion angle should be considered in their design and use to reduce puncture failure rates.
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INTRODUCTION: Multiple punctures during peripheral venous catheter (PVC) placement increase the risk of complications. Scoring for adult difficult intravenous access (A-DIVA Scale) exists but has never been assessed in the framework of a care algorithm (scoring associated with a new decision-making tree for puncture conditions, the A-DIVA Tree). We seek to implement an catheter placement algorithm to decrease the mean number of punctures per patient. The algorithm will be adjusted based on obstacles and levers revealed by the analysis of clinical data. The benefits of the algorithm will be assessed using a step-by-step implementation of the approach. METHODS AND ANALYSIS: 794 PVC placements will be recorded in two inclusion centres (50%/50%). In phase I, 297 PVC placements will be collected, and 16 individual semistructured interviews will be conducted to evaluate the centres' practices. In phase II, 200 PVC placements will be recorded to assess the impact of the A-DIVA Scale alone. The interphase will allow preliminary results based development of the A-DIVA Tree. In phase III, 297 PVC placements will be recorded to assess the impact of the algorithm on the mean number of punctures per patient. ETHICS AND DISSEMINATION: The study and related consent forms were approved by an institutional review board (Comité de Protection des Personnes Sud-Méditerranée I) on 25 April 2023 under reference number 2023-A00223-42. The results will be disseminated in the form of original articles, presentations and guidelines. TRIAL REGISTRATION NUMBER: NCT05935228.
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Algoritmos , Cateterismo Periférico , Humanos , Cateterismo Periférico/métodos , Punções/métodos , AdultoRESUMO
PURPOSE OF REVIEW: The objective of the current review is to examine the likelihood of improved safety in peripheral nerve blockade attributable to ultrasound guidance. RECENT FINDINGS: With ultrasound guidance, a 10-fold reduction in the incidence of local anesthetic systemic toxicity as well as a tendency toward less long-term neuropathies are shown. SUMMARY: Ultrasound is clearly superior to other techniques with the aim of achieving maximum efficacy with minimum risk: a win-win approach.
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Bloqueio Nervoso/métodos , Ultrassonografia de Intervenção/métodos , Anestésicos Locais/efeitos adversos , Estimulação Elétrica , Humanos , Bloqueio Nervoso/efeitos adversos , Doenças do Sistema Nervoso/etiologia , Nervos Periféricos/efeitos dos fármacosRESUMO
BACKGROUND: There is ongoing debate regarding the optimal general anaesthetic technique for manual removal of the placenta after vaginal delivery. Using ultrasound examination of the gastric antrum, this study aimed to assess the change in gastric contents during vaginal delivery and to determine the prevalence of stomach at risk for pulmonary aspiration in the immediate postpartum period before placental delivery. METHODS: In this prospective multicentre cohort study, antral ultrasonography was performed at full cervical dilatation within the thirty minutes preceding the beginning of expulsive efforts and after vaginal birth, before placental delivery. High-risk gastric content was defined as the visualisation of any solid content in the antrum or antral cross-sectional area in the semi-recumbent position (SR-CSA) > 608 mm². RESULTS: Twenty-six women were included and analysed. There was a significant decrease in both the proportion of patients with solid gastric content and the SR-CSA between the two-ultrasound examinations. Twenty-one patients (80.8%) exhibited a decrease in the SR-CSA during vaginal delivery. The prevalence of stomach at risk for pulmonary aspiration was significantly lower after vaginal delivery than before vaginal delivery (23.1% vs. 57.7%, P = 0.0004). CONCLUSION: Our results suggest that gastric emptying is at least partially preserved during vaginal birth. Nevertheless, almost a quarter of women did have high-risk gastric content in the immediate postpartum period. Point-of-care antral ultrasonography may be of interest for the fast assessment of the gastric content status when a general anaesthesia is required for manual removal of retained placenta.
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Parto Obstétrico , Placenta , Estudos de Coortes , Feminino , Humanos , Placenta/diagnóstico por imagem , Gravidez , Estudos Prospectivos , UltrassonografiaRESUMO
BACKGROUND: Arterial cannulation is an important procedure for hemodynamic monitoring and blood sampling. Traditional radial artery cannulation is performed by using anatomical knowledge and pulse palpation as a guide. Arterial cannulation using ultrasound (US) requires specific training, especially for new US users. We hypothesized that even for new US users, US guidance would facilitate the successful puncture by lower attempts before successful intraluminal cannulation of a simulation model of the radial artery. METHODS: A prospective randomized controlled crossover study was conducted with new US users on a gelatin phantom wrist. Three sessions of training were proposed: US-guided technique with low blood pressure (BP), palpation-guided technique with high BP, and one secondary comparison with low BP. For the 2 first sessions, all volunteers performed each technique but not in the same order. The main criterion was the number of attempts before successful catheterization of the model artery. A secondary criterion was the number of needle movements (the number of attempts plus the number of needle directional changes). RESULTS: Twenty new US users participated in the study. Numbers of attempts before successful catheterization were significantly lower when using the US technique: 1.1 (± 0.4) for US versus 1.6 (± 0.8) for palpation high BP (P = .02) versus 2.5 (± 1.4) for the secondary comparison, palpation low BP (P < .001). All of the participants achieved success after the 12th needle movement for US technique, after the 19th needle movement for palpation high BP, and after the 25th needle movement for the secondary comparison, palpation low BP. The total time before success was not significantly different between the 2 first sequences (US vs palpation high BP). CONCLUSIONS: US technique was more successful than traditional palpation technique for novice US users performing arterial cannulations for the first time. A study in the clinical practice is needed to confirm these results.
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Cateterismo Periférico , Hipotensão , Treinamento por Simulação , Cateterismo Periférico/métodos , Estudos Cross-Over , Humanos , Palpação/métodos , Estudos Prospectivos , Artéria Radial/diagnóstico por imagem , Ultrassonografia de IntervençãoRESUMO
Aim: To compare the reliability of transtracheal ultrasound to confirm the endotracheal tube position with saline versus air inflated cuff. Methods: This was a prospective randomized cadaveric study. Four techniques were randomized: endotracheal tube in the trachea with air or saline inflated cuff, and endotracheal tube in the esophagus with air or saline inflated cuff. The investigator used the Mcgrath to randomly place the endotracheal tube in the trachea or in the esophagus with saline or air inflated cuff. During the first series of measurements, nine residents performed transtracheal ultrasound with linear transducer placed transversely at the suprasternal notch. They were recorded with a cut off fixed to 30 seconds, and a questionnaire was completed by the residents after each transtracheal ultrasound in order to report where the endotracheal tube is positioned according to them. The second series followed the same protocol and included three residents who had participated in the first series. The primary outcome was the success rate in determining the position of the endotracheal tube. Results: In the first series, the success rate was 46.5%. In the second series, the success rate was 72.9%. There was no significant difference between cuff inflated with saline and air (p = 1.00). The overall mean time required was 20.6 s (95% CI 13.0-28.2 s). Based on an empirical data set, transtracheal ultrasound had a sensitivity of 62.2%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 26.08%. Conclusion: This investigation shows that regardless of the contents of the endotracheal tube cuff, the use of transtracheal ultrasound to confirm the position of endotracheal tube reports disappointing results.
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BACKGROUND: Peripheral intravenous access is a common medical procedure, however, it can be difficult to perform in some patients. Success rates have proved greater with ultrasound guidance. Peripheral intravenous access using ultrasound requires specific training, especially for new ultrasound users. To overcome these difficulties, guidance devices on ultrasound probes are able to control the angle of penetration into tissues. We hypothesized that, and particularly for new ultrasound users, the use of a needle guide (NG) paired with the out-of-plane approach would facilitate puncture of a simulation model of vessel more effectively than similar free hand (FH) techniques. METHODS: A prospective controlled randomized study was conducted of new ultrasound users using a guide wire introducer needle on gelatine phantom. After a 30-min lecture, one group performed the FH technique and the other group performed the NG technique both in an out-of-plane approach. The main criterion was the number of attempts before success of catheterization of this model of vessel. RESULTS: Thirty-four nurse anesthetist students participated in the study. The number of attempts before success using the NG technique was significantly lower: 3.7 (±0.9) in the NG group versus 6.7 (±3.3) in the FH group (p = 0.01). In the NG group, 100% of the participants achieved success after the sixth attempt. In the FH group, only 81.25% (n = 13/16) reached success. CONCLUSION: NG technique has been proved to have a steeper learning curve compared with the FH technique. A study on a learning curve in clinical practice is needed to confirm these results.
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Flebotomia , Ultrassonografia de Intervenção , Humanos , Estudos Prospectivos , Punções , UltrassonografiaRESUMO
We report a pudendal nerve injury that developed after a posterior approach to the sciatic nerve. A classical Labat's posterior sciatic nerve block on the right side was performed using an insulated needle and a nerve stimulator set at an initial current of 2 mA, 2 Hz frequency, and 0.1 ms duration. Painful paresthesia radiating to the right side of the patient's penis and right leg was experienced shortly after needle insertion. The needle was immediately withdrawn and redirected laterally. Motor responses for the common peroneal and tibial components of the sciatic nerve were elicited at 0.48 mA in both cases and a 10-mL bolus of mepivacaine 1.5% was injected onto each component. The sciatic nerve block was combined with a femoral nerve block to facilitate a knee arthroscopy. The trauma resulted in erectile dysfunction and partial loss of penile sensation as well as evidence of injury to the sciatic nerve itself. Symptoms and clinical signs of pudendal nerve injury lasted 7 months. This is the first time that sexual dysfunction as a result of a unilateral pudendal nerve injury that occurred after a posterior sciatic nerve block has been reported.
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Disfunção Erétil/etiologia , Bloqueio Nervoso/efeitos adversos , Pelve/inervação , Traumatismos dos Nervos Periféricos , Nervo Isquiático , Artroscopia , Procedimentos Cirúrgicos Eletivos , Estimulação Elétrica , Humanos , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Parestesia/etiologia , Fatores de TempoRESUMO
INTRODUCTION: This observational study was designed to assess the use of spinal anesthesia with chloroprocaine in the context of ambulatory surgery. METHODS: A prospective, multicenter, observational study was carried out among 33 private or public centers between May 2014 and January 2015 and adult patients, scheduled for a short ambulatory surgery under spinal anesthesia with chloroprocaine. The primary outcomes were anesthetic effectiveness, defined as performance of the whole surgical procedure without any additional anesthetic agent, and the time to achieve eligibility for hospital discharge. Secondary outcomes were the effect of chloroprocaine on motor and sensory blocks, patients' satisfaction, and the use of analgesics in the first 24 h after surgery. RESULTS: Among the 615 enrolled patients, 56% were male, the mean age was 47.2 ± 15.2 years, and most patients had an ASA (American Society of Anesthesiologists) status of 1 (63.7%). Main surgical procedures performed were orthopedic (62.6%) and gynecologic (16.1%), and the mean duration of surgery was 26.7 ± 16.7 min. The overall anesthetic success rate was 93.8% (95% CI [91.5%; 95.6%]) for the 580 patients with available data for primary criteria. The failure rate was lower than 7% for all surgical procedures, except for gynecologic surgery (14.8%; 95% CI [8.1%; 23.9%]). The average times of eligibility for hospital discharge and effective discharge were 252.7 ± 82.7 min and 313.8 ± 109.9 min, respectively. The time of eligibility for hospital discharge is defined as the recovery of the patient's normal clinical parameters and the time of effective discharge is defined as the time for the patient to leave the hospital after surgery. Eligibility for patient's discharge was achieved more rapidly in private than public hospitals (236.3 ± 77.2 min vs. 280.9 ± 80.7 min, respectively, p < 0.001). CONCLUSIONS: This study showed positive results on the effectiveness of chloroprocaine as a short-duration anesthetic and could be used to reduce the time to achieve eligibility for hospital discharge. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02152293. Registered on May 6, 2014. Date of enrollment of the first participant in the trial May 7, 2014.
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Procedimentos Cirúrgicos Ambulatórios/estatística & dados numéricos , Raquianestesia/métodos , Anestésicos Locais/uso terapêutico , Alta do Paciente/estatística & dados numéricos , Procaína/análogos & derivados , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Procaína/uso terapêutico , Estudos Prospectivos , Fatores de Tempo , Adulto JovemRESUMO
INTRODUCTION: Available short-acting intrathecal anesthetic agents (chloroprocaine and prilocaine) offer an alternative to general anesthesia for short-duration surgical procedures, especially ambulatory surgeries. Factors determining the choice of anesthesia for short-duration procedures have not been previously identified. METHODS: This observational, prospective, multicenter, cohort study was conducted between July 2015 and July 2016, in 33 private or public hospitals performing ambulatory surgery. The primary objective was to determine the factors influencing the choice of anesthetic technique (spinal or general anesthesia). Secondary outcomes included efficacy of the anesthesia, time to hospital discharge, and patient satisfaction. RESULTS: Among 592 patients enrolled, 309 received spinal anesthesia and 283 underwent general anesthesia. In both study arms, the most frequently performed surgical procedures were orthopedic and urologic (43.3% and 30.7%, respectively); 66.1% of patients were free to choose their type of anesthesia, 21.8% chose one of the techniques because they were afraid of the other, 16.8% based their choice on the expected ease of recovery, 19.2% considered their degree of anxiety/stress, and 16.9% chose the technique on the basis of its efficacy. The median times to micturition and to unassisted ambulation were significantly shorter in the general anesthesia arm compared with the spinal anesthesia arm (225.5 [98; 560] min vs. 259.0 [109; 789] min; p = 0.0011 and 215.0 [30; 545] min vs. 240.0 [40; 1420]; p = 0.0115, respectively). The median time to hospital discharge was equivalent in both study arms. In the spinal anesthesia arm, patients who received chloroprocaine and prilocaine recovered faster than patients who received bupivacaine. The time to ambulation and the time to hospital discharge were shorter (p < 0.001). The overall success rate of spinal anesthesia was 91.6%, and no significant difference was observed between chloroprocaine, prilocaine, and bupivacaine. The patients' global satisfaction with anesthesia and surgery was over 90% in both study arms. CONCLUSIONS: Patient's choice, patient fear of the alternative technique, patient stress/anxiety, the expected ease of recovery, and the efficacy of the technique were identified as the main factors influencing patient choice of short-acting local anesthesia or general anesthesia. Spinal anesthesia with short-acting local anesthetics was preferred to general anesthesia in ambulatory surgeries and was associated with a high degree of patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02529501. Registered on June 23, 2015. Date of enrollment of the first participant July 21, 2015.
Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Anestesia Geral/tendências , Raquianestesia/tendências , Satisfação do Paciente/estatística & dados numéricos , Adulto , Anestésicos Locais/uso terapêutico , Bupivacaína/uso terapêutico , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procaína/análogos & derivados , Procaína/uso terapêutico , Estudos Prospectivos , Fatores de TempoRESUMO
BACKGROUND: Whereas 5415 Intensive Care Unit (ICU) beds were initially available, 7148 COVID-19 patients were hospitalised in the ICU at the peak of the outbreak. The present study reports how the French Health Care system created temporary ICU beds to avoid being overwhelmed. METHODS: All French ICUs were contacted for answering a questionnaire focusing on the available beds and health care providers before and during the outbreak. RESULTS: Among 336 institutions with ICUs before the outbreak, 315 (94%) participated, covering 5054/5531 (91%) ICU beds. During the outbreak, 4806 new ICU beds (+95% increase) were created from Acute Care Unit (ACU, 2283), Post Anaesthetic Care Unit and Operating Theatre (PACU & OT, 1522), other units (374) or real build-up of new ICU beds (627), respectively. At the peak of the outbreak, 9860, 1982 and 3089 ICU, ACU and PACU beds were made available. Before the outbreak, 3548 physicians (2224 critical care anaesthesiologists, 898 intensivists and 275 from other specialties, 151 paediatrics), 1785 residents, 11,023 nurses and 6763 nursing auxiliaries worked in established ICUs. During the outbreak, 2524 physicians, 715 residents, 7722 nurses and 3043 nursing auxiliaries supplemented the usual staff in all ICUs. A total number of 3212 new ventilators were added to the 5997 initially available in ICU. CONCLUSION: During the COVID-19 outbreak, the French Health Care system created 4806 ICU beds (+95% increase from baseline), essentially by transforming beds from ACUs and PACUs. Collaboration between intensivists, critical care anaesthesiologists, emergency physicians as well as the mobilisation of nursing staff were primordial in this context.