Patient de réanimation,journées de réanimation ? Modélisation d’un fonctionnement optimisé des unités de réanimation,de soins intensifs et de surveillance continue et conséquences sur les suppléments tarifaires induits

Introduction

“Critical Care Units” are intended to admit patients with multiple organ failure. The severity of patients admitted is variable. The aim of the study was to estimate the number of days that an optimum care organization could release, and therefore the additional admissions that would have been allowed. Estimates of earnings related to the various supplements were carried out jointly.

Methods

Reporting days associated or not with a resuscitation care during the year 2011 in an ICU of a university hospital (16 beds), optimized patient flow simulation, and computation of medical act inducing financial supplements.

Results

Six hundred and fifty-seven patients (SAPS II from 0 to 110, 41% ventilated more than 48 hours, mortality = 26%) were admitted representing 5095 days (occupancy rate = 87%). Two hundred and twenty-two patients (34%) did not trigger supplement for resuscitation care for 415 days in the unit. Four hundred and thirty-five patients have triggered this supplement representing 4680 days, including 3035 days with resuscitation care and 1645 (35% of days valued resuscitation, 32% of total days) without any. The entire year 2011 has generated earnings of 3,980,192 €. Optimization of management would have allowed the admission of additional 235 to 295 patients and potential additional earnings from 524,735 € to 1,063,804 €, depending on the occupancy rate chosen (80% or real 2011s) and the severity of discharged patients.

Conclusion

Optimization of the patients flow between “Critical Care”, Intensive Care and Continuous Monitoring Units would increase the number of patients admitted in “Critical Care” Units without any financial loss related to supplements.     

La sédation–analgésie au quotidien : enquête de pratiques auprès de 218 services de réanimation en France

Objectives

To assess the current use of sedation and analgesia in a large sample of French intensive care units (ICUs) and to define structural characteristics of the units that use a written procedure.

Study design

Self-reported survey.

Participants

Three hundred and sixty French ICUs were presented the questionnaire in September 2007.

Results

Surveys were received from 228 (60.6%) ICUs. Midazolam was used in more than 50% of the patients in 79.2% of the ICUs and propofol in 22.2% of the ICUs. Sufentanil was the most frequently used morphinic. A sedation-scale was used in 68.8% of the units (80.3% Ramsay score). Sedation was assessed at least every 4 hours in 61% of ICUs. A pain-scale was used in 88.9% of the ICUs, but only 12.5% in the non-communicant patients. A written procedure was used in 29.4% of the units only. In multivariate analysis, use in the ICU of a written procedure for the early management of patients with septic shock and/or intensive insulin therapy was the single variable significantly associated with presence of a written procedure for sedation and analgesia (respectively OR 4.37; p < 0.0001 and OR 5.64; p = 0.032).

Conclusion

Although more than two-third of the responding ICUs reported the use of sedation-and-pain-scales, frequency of assessment was low, and objective assessment of pain in the non-communicating patients was extremely uncommon. Similarly, the use of written procedure was low. The use of sedation-analgesia written procedure in an ICU seems strongly influenced by a more global involvement of the ICU in the protocolisation of complex care. These findings support the reinforcement of educational programs.     

La personne de confiance est-elle un témoin fiable en cas de possibilité de prélèvement d’organe sur personne décédée en vue d’un don ?

Objectives

All adults (people over the age of 18) can assign a person of trust and this person can be a parent, a partner or the treating doctor. Following the introduction of the 4^th March 2002 law, this third party is now within the doctor–patient relationship. The aim of this study is to find out who is appointed as a person of trust by patients notably concerning the level of education or medical knowledge of these people. We have equally put the person of trust to the test within the realms that they would be questioned regarding organ donation from the deceased.

Patients and methods

The included subjects were adults admitted to hospital for surgical procedures or medical biopsies that were not deemed life threatening. The data collection was done by doctors from the legal medicine department at the university hospital of Amiens over a period of 18 months. With the permission of the patient and his or her person of trust, a one-to-one discussion was held. Statistical analysis took place focusing on all the variables together and is shown by comparing the patient group versus the person of trust group. The significance threshold returned was 0.05.

Results

A total of 125 patients–persons of trust couples were interviewed. The patients and their person of trust were not different in terms of age, social status, occupational groups and education. However, a person of trust is more often a woman (64%) against 50% of patients. A person of trust more often lives as a couple than the patients. Concerning organ donation, over half of the people questioned were for donation but only a third of patients had already discussed the subject with their person of trust. The persons of trust bring in 40% of cases a response that is not concordant in the position of the patient.

Discussion

The creation of a person of trust due to the law of 4^th March 2002 brings about the opportunity for the patient to take on an approach, with the doctors, of having somebody that can advise them. Yet in this study, there is no significant evidence of a difference between the level of education of patients and that of their person of trust, or a difference in the distribution of the socio-professional categories, or specific choices for the GP. The person of trust can be used to wait on behalf of the patient whilst he or she is not able to do so. Even if the patient feels that the person of trust has come first over other close friends or relatives, the persons of trust assume this role with difficulty. Since its creation, the person of trust was presented as a response to social demand; however, it seems that patients are not sufficiently informed when it comes to the possibilities that are on offer to them.     

Motifs de primo-consultations de néphrologie en 2014 dans le territoire de santé 5 de Bretagne

BackgroundIn France, the coordinated healthcare circuit means that patients should be referred to specialists, for example nephrologists, by another physician. However, there are no recommendations concerning the reasons justifying the referral to a nephrologist. The main purpose of our study is to describe the motif of first consultations in nephrology in the health area 5 of Brittany.MethodsWe retrospectively collected medical reports of first consultations by 17 nephrologists in the 4 centers of the study area, during the year 2014. In these letters, we noted the consultation motif, the specialty of the physician who refers the patient, and main characteristics of patients.ResultsWe included 662 first consultations. The main reason for consultations was chronic kidney disease (68.7%), including chronic renal insufficiency (56.9%), proteinuria (7.3%), microscopic hematuria (3.3%) and searching for chronic kidney disease in the presence of risk factor (1.2%). Other frequent reasons were the follow-up consultation after a pregnancy complicated by preeclampsia (9.5%), urinary lithiasis (5.7%), hypertension (3.8%) and hydroelectrolytic disorder (3.5%). Non-nephrology reasons represent 3.2% of first consultations. Almost all patients have been referred by a physician (99.7%), mainly a general practitioner (71.9%).ConclusionNephrology first consultations are realized according to the coordinated healthcare circuit since almost all are requested by another physician. The reasons are adapted to the specialty. The main reason is chronic kidney disease, often already associated with renal insufficiency chronic.     

Repérage de la membrane cricothyroïdienne en phase d’apprentissage : valeur ajoutée de l’échographie ?

Objectives

Emergency cricothyroidotomy is recommended as life-saving maneuver when mask ventilation and tracheal intubation are impossible. It requires the puncture of the cricothyroid membrane (CTM) whose clinical identification is difficult. The objective of this study is to evaluate if ultrasound can help locating the CTM by comparing palpation and ultrasonographic evaluation.

Patients and methods

After ultrasound localization of CTM by a referent physician in two overweight volunteers, twelve residents without prior anatomy recall, defined by palpation an entry point for CTM. After a rapid training in CTM ultrasound localization, residents identified an ultrasound-guided puncture point. For each puncture site were registered: relevance, time and ease to localization. Six months later, residents renewed clinical and ultrasound identification of CTM on the same subjects.

Results

The CTM was accurately identified by palpation and ultrasound by 46% and 100% of residents respectively (P < 0.05). Six months later, residents remained more effective identifying CTM with ultrasound than with palpation (78% vs. 33%) (P < 0.05). Time to localization of CTM by palpation in the 2 volunteers was 15 s [11–18] and 24 s [9–39] (average [CI 95%]) whereas it was 21 s [16–25 s] and 28 s [19–36] by ultrasound respectively (ns). The ultrasound identification of CTM was also considered easier than clinical identification.

Conclusion

Following a limited training phase, ultrasound allowed a more effective localization of CTM by residents when compared to clinical palpation in overweight patients. This benefit remained significant when assessment was repeated 6 months later.     

Prothèse Roseland® : étude de qualité de vie de 68 patients avec un recul moyen de 43,8 mois

ObjectivesRoseland^® prosthesis is a ball and socket prosthesis, physiological and not anatomical. This study wants to demonstrate by a quality life questionnaire (quick DASH described by Dubert et al., 2001 [1]) that Roseland^® prosthesis gives to patients a trapeziometacarpal joint native capacities.Patients and methodsAn exterior examinator reviewed prospectively 68 patients having a mean age of 61,1 years at surgery with 11 bilateral cases that is 79 prothesis. With a mean follow-up of 43.8 months, we value by Kapandji's opposition, first comisssural openning, quality of life and patient's satisfaction.ResultsThree patients have been excuded: two of them had got post-traumatic dislocation: one trapezium fracture, one unknown reason. The third patient had got osteophytis with “came” effects. We keep 65 patients with 84,6% satisfying and very satisfaying. 75,4% of patients have a capacity of 80% and more of their joint, 40% of them had got 100%.DiscussionRoseland^® prosthesis has good results because it agrees with already known principles as on its own concept: rotula prothesis gives three axes mobility, as on its own conception: metarcarpal stem with a palmar “T” shaped against rotation and bone saving, a cup with equatorial ring to prevent burying of the spongy bone. Componenents are recovered by hydroxyapatite to favour osteo-integration with less loosening than ciment. An accurate technique avoids dislocations traps: trapezium implant centring, internal osteophytis removal. An accurate indication: trapeziometarpal joint osteoarthritis only (second degree's Dell classification).ConclusionRoseland^® prosthesis reproduces a satisfactory and functional joint for 84,6% of cases. These good results can be obtained by accurate indication (Dell II) and contra-indication (osteoarthritis around trapezium except trapeziometacarpal of course).     

L’adjonction de sulfate de magnésium à la morphine en intrathécal améliore-t-elle l’analgésie après césarienne ?

Background

Intrathecal morphine (IT) is commonly used for postoperative analgesia after caesarean section. The addition of intrathecal (IT) magnesium to spinal bupivacaine-fentanyl anaesthesia increases the duration of spinal analgesia for labour without additional side effects. In this prospective, randomized, double blind, controlled study, we evaluated whether adding intrathecal magnesium could prolong spinal morphine analgesia after caesarean section.

Parturient and methods

After ethics committee approval and obtaining written consent, one hundred and five (ASA I or II) adult patients undergoing caesarean section were recruited. They were randomly allocated to one of three groups: (1) group Morphine (M): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 μg morphine (1 ml) + 10 μg fentanyl (0.1 ml) + 1 ml of isotonic saline solution, (2) group Magnesium (Mg): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 mg of magnesium sulphate 10% (1 ml) + 10 μg fentanyl (0.1 ml) + 1 ml of isotonic saline solution, (3) group Morphine + Magnesium (MMg): 10 mg of isobaric bupivacaine 0.5% (2 ml) + 100 mg of magnesium sulphate 10% (1 ml) + 100 μg morphine (1 ml) + 10 μg fentanyl (0.1 ml).We recorded the following: time to the first analgesic request, pain scores with the visual analogic scale at rest and in movement at h0, h1, h2, h4 and then every 4 h for the first 36 postoperative hours, the occurrence of adverse events and patients’ satisfaction.

Results

Time of the first analgesic request was 28 ± 8 h in group MMg versus 19 ± 6 h in group M and 7 ± 6 h in group Mg (p < 0.01). Pain scores were statistically lower in group MMg (9 ± 7 and 17 ± 9 mm respectively) compared to group M (16 ± 9 and 28 ± 11 mm respectively) and Mg (21 ± 9 and 37 ± 13 mm respectively) (p < 0.01). There was no difference in adverse events among the three groups. Patients satisfaction was better in group MMg (p < 0.01).

Conclusion

In patients undergoing caesarean section under spinal anaesthesia, the addition of IT magnesium sulphate (100 mg) to morphine 100 μg improved the quality and the duration of postoperative analgesia without increasing the incidence of adverse effects.     

Tratamiento del tumor vesical no músculo infiltrante frente al problema de disponibilidad de bacilo de Calmette-Guerin. Consenso de un panel de expertos españoles

ContextSince June 2012, the has been a worldwide lack of available of the Connaught strain. In December 2012, a group of experts met in the Spanish Association of Urology to analyze this situation and propose alternatives.ObjectiveTo present the work performed by said committee and the resulting recommendations.Acquisition of evidenceAn update has been made of the principal existing evidence in the treatment of middle and high risk tumors. Special mention has been made regarding the those related with the use of BCG and their possible alternative due to the different availability of BCG.Evidence synthesisIn tumors with high risk of progression, immediate cystectomy should be considered when BCG is not available, with dose reduction or alternating with chemotherapy as methods to economize on the use of BCG when availability is reduced. In tumors having middle risk of progression, chemotherapy can be used, although when it is associated to a high risk of relapse, BCG would be indicated if available with the mentioned savings guidelines. BCG requires maintenance to maintain its effectiveness, it being necessary to optimize the application of endovesical chemotherapy and to use systems that increase its penetration into the bladder wall (EMDA) if they are available.ConclusionsDue to the scarcity of BCG, it has been necessary to agree on a series of recommendations that have been published on the web page of the Spanish Association of Urology.     

Cartographie du risque d’être transfusé en chirurgie au CHU de Lyon : un outil de rationalisation de la prescription des examens immunohématologiques (Hospices civils de Lyon – HCL)

Introduction

Immunohaematology examinations are usually prescribed preoperatively according to more or less standardized protocols. We wanted to assess the relevance of these protocols on the basis of factual data: an overview of the rate of transfusions carried out as part of surgery within the HCL in 2009.

Study design

The list of patients operated in 2009 in the HCL (IPOP by Cristalnet) has been combined with the list of patients transfused in the same time period (CTS server, Inlog). The percentage of patients transfused during the stay, and the percentage of patients transfused on the day of the intervention itself were determined for each type of surgery. The study focused on 13 571 patients affected by 44 surgeries.

Patients and methods

Six hundred and thirty-three patients were transfused, 45% of them the day of the intervention. The risk of needing to carry out a transfusion depends on the risk to the patient and surgery. For example, the total hip arthroplasty transfusion risk is 11.9% when it's programmed against 37.8% in emergency surgery. The transfusion risk of knee arthroscopies, osteosynthesis of wrist fracture, carpal canal surgeries and of appendectomies, thyroidectomies, herna repair surgeries are below 0.5%. The transfusion risk of colectomy is 18.1%. Thus, new recommendations for good clinical practices on the relevance of settled surgery-preoperative immunohematologic exams can be established.

Conclusion

The emergency degree of the transfusion must be taken into account for such recommendation. Each hospital should perform its own cartography to justify its own protocols.     

Optimisation de l’administration des agents anesthésiques inhalés : débit de gaz frais ou fraction délivrée ?

Introduction

During volatile closed-circuit anaesthesia, a chosen end-tidal fraction (Fet) could be achieved by setting either delivered fraction (Fd) or fresh gas flow (FGF). This study compared the efficacy of both strategies and the resulting drug consumption.

Patients and methods

Sixty patients (10 per group) were administered, after intravenous induction and intubation, desflurane, sevoflurane or isoflurane + 50% N₂O, to achieve a target Fet equal to one minimal alveolar concentration (MAC), according to one strategy: high FGF (HFGF) Fd fixed 20% above target Fet, FGF 10 l/min then 1 l/min after achieving the target, FGF opened at 10 l/min at the end of surgery; low FGF (LFGF) FGF fixed at 1 l/min, Fd at the maximal value on the vaporizer, then set at target Fet + 20% after achieving Fet equal to one MAC, FGF maintained at 1 l/min until extubation.

Results

The target Fet was achieved in all patients in LFGF within 2.1 ± 0.9 min followed by 15% (isoflurane) to 57% (sevoflurane) overdosage, but only in nine patients out of 30 after 10 min in HFGF. Delays were similar between desflurane and sevoflurane. Volatile consumption was decreased by 75% in LFGF. Fifty percent decrement and extubation times were shorter with HFGF, similarly for the three agents.

Conclusion

Massive overdosage of Fd is the fastest, reproducible and cheapest strategy to achieve (or to increase) a chosen Fet. High FGF is the fastest to decrease Fet during or at the end of anaesthesia. Combining Fd and FGF adjustments in order to maximize Fd/Fet gradients overwrites pharmacokinetic differences between desflurane and sevoflurane and reduces differences with isoflurane. Automatic adjustments based on volatile pharmacockinetics would be helpful to achieve a target Fet without overdosage.     

Estudio prospectivo de los factores asociados al delirium en el postoperatorio de la cirugía abdominal urgente

IntroductionDelirium is a frequent complication in elderly patients after urgent abdominal surgery.MethodsProspective study of consecutive patients aged ≥ 65 years who had undergone urgent abdominal surgery from 2017-2019. The following variables were recorded: age, sex, ASA, physiological state, cognitive impairment, frailty (FRAIL Scale), functional dependence (Barthel Scale), quality of life (Euroqol-5D-VAS), nutritional status (MNA-SF), preoperative diagnosis, type of surgery (BUPA Classification), approach and diagnosis of postoperative delirium (Confusion Assessment Method). Univariate and multivariate analyses were performed to analyze the correlation of these variables with delirium.ResultsThe study includes 446 patients with a median age of 78 years, 63.6% were ASA ≥ III and 8% had prior cognitive impairment. 13.2% were frail and 5.4% of the patients had a severe or total degree of dependence. 13.6% developed delirium in the postoperative period. In the univariate analysis, all the variables were statistically significant except for sex, type of surgery (BUPA) and duration. In the multivariate analysis the associated factors were: age (P < .001; OR: 1,08; 95% CI: 1,038-1,139), ASA (P = .026; OR: 3.15; 95% CI: 1.149-8.668), physiological state (P < .001; OR: 5.8; 95% CI: 2.176-15.457), diagnosis (P = .006) and cognitive impairment (P < .001; OR: 5.8; 95% CI: 2.391-14.069).ConclusionThe factors associated with delirium are age, ASA, physiological state in the emergency room, preoperative diagnosis and prior cognitive impairment.