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The purpose of benchmarking is to settle improvement processes by comparing the activities to quality standards. The proposed methodology is illustrated by benchmark business cases performed inside medical plants on some items like nosocomial diseases or organization of surgery facilities. Moreover, the authors have built a specific graphic tool, enhanced with balance score numbers and mappings, so that the comparison between different anesthesia-reanimation services, which are willing to start an improvement program, is easy and relevant. This ready-made application is even more accurate as far as detailed tariffs of activities are implemented.

Resume Objectifs Synthetiser les preuves les plus recentes sur l'utilite et l'innocuite des anti-inflammatoires utilises en perioperatoire. Source des donnees Les references ont ete obtenues par interrogation des bases de donnees electroniques (termes medicaux : AINS, coxibs, steroides, chirurgie, anesthesie) puis completes par une recherche manuelle. Synthese des donnees Les AINS, les coxibs et les steroides utilises seuls ou en association se sont montres efficaces pour traiter la douleur postoperatoire. Cependant, le benefice perioperatoire des anti-inflammatoires peut aller au-dela de l'analgesie postoperatoire. Les anti-inflammatoires se sont reveles efficaces dans certaines situations pour diminuer l'incidence des effets secondaires des morphiniques et des nausees-vomissements postoperatoires ou pour ameliorer la recuperation apres une chirurgie. Toutefois, les AINS ont ete reconnus comme etant un facteur de risque pour la reprise chirurgicale apres certains actes chirurgicaux. A l'inverse, les coxibs sont impliques dans la survenue de thromboses arterielles apres certaines chirurgies.

Resume Objectifs : Presenter des questionnaires d’enquete et un logiciel informatique specifique pour le traitement des donnees, permettant la realisation de demarches d’assurance qualite dans le domaine de la prise en charge des douleurs postoperatoires. Type d’etude : Etude descriptive. Methodes : Un comite de pilotage forme de medecins anesthesistes, d’infirmier(e)s et d’epidemiologistes a elabore et teste trois questionnaires d’enquetes pour evaluer la satisfaction des patients, du personnel infirmier et medical. A partir de la version definitive des questionnaires, un logiciel specifique a ete cree, permettant une analyse rapide des points de dysfonctionnements dans l’organisation de la prise en charge des douleurs postoperatoires. Apres cette mise au point, ce materiel a ete employe dans trois etablissements hospitaliers differents (A, B et C). Resultats : Les resultats des enquetes effectuees ont pu etre pris en consideration, quand le taux des repondeurs etaient superieur a 50 %. Les points de dysfonctionnement ont ete classes en 4 niveaux : le point de vue des patients (ex : les douleurs postoperatoires persistaient pour plus de 50 % des patients), le bilan des pratiques (ex : 42 a 72 % des soignants declaraient connaitre les protocoles antalgiques en vigueur dans leur service), le bilan des attitudes (ex : 19 a 34 % des soignants pensaient encore qu’une douleur de base est utile pour la surveillance) et le potentiel du service (ex : 21 a 61 % du personnel infirmier et medical avaient recu une formation specifique sur la prise en charge de la douleur). Les avantages et les inconvenients de ce materiel (questionnaires et logiciel) ont ete discutes et les modalites d’utilisation qui en decoulent ont ete definies. Conclusion : Le materiel expose ici devrait permettre aux equipes soignantes d’evaluer la qualite de l’organisation de la prise en charge des douleurs postoperatoires. Sa validation, qui est en cours, permettra de perfectionner cet outil en gardant les indicateurs les plus performants temoignant d’une prise en charge correcte de la douleur aigue postoperatoire.

Resume Objectif : Determiner l’influence de l’analgesie peridurale (APD) sur le taux de cesariennes et d’extractions instrumentales au cours du travail obstetrical. Source des donnees : Recherche dans la banque de donnees Medline®, des etudes prospectives effectuees depuis 1989 comparant l’APD a une analgesie intraveineuse. Les donnees comprennent aussi une analyse des etudes anterieures a 1989 qui ont ete uniquement retenues pour les informations procurees sur les mecanismes etiologiques des modifications induites par l’APD. Synthese des donnees : L’APD prolonge la premiere et la seconde phase du travail et augmente l’incidence des extractions instrumentales sans effet nefaste chez les nouveau-nes (apprecie sur le score d’Apgar et le pH). L’APD n’augmente ni l’incidence globale des cesariennes ni celle des cesariennes realisees pour dystocie. La reduction, grâce aux opiaces, de la concentration des solutions d’anesthesiques locaux administres en peridurale, a permis de reduire l’incidence du bloc moteur pelvien, element implique dans l’allongement de la seconde partie du travail. Les modes d’extraction sous peri-rachianesthesie sequentielle sont identiques a ceux obtenus avec l’APD. Ni l’usage de nouveaux agents anesthesiques comme la ropivacaine, ni la deambulation ne semblent avoir d'impact significatif sur le taux de cesariennes. Conclusions : Les modifications des techniques analgesiques peridurales, associees aux changements de la conduite obstetricale (rupture des membranes, ocytociques systematiques) ont permis d’assurer une analgesie de qualite n’ayant qu’une influence moderee sur le travail, limitee a l’allongement de sa duree, et a une frequence plus elevee de delivrances instrumentales, mais sans majoration du taux des dystocies.

Resume Objectif : Aucune donnee ni mise au point n’est disponible en France sur le probleme de la toxicomanie chez les medecins anesthesistes. L’objectif de cet article a donc ete de rassembler un certain nombre d’elements permettant d’apprehender ce probleme. Source de donnees : Une analyse de la litterature existante sur la toxicomanie en milieu anesthesique a ete effectuee a partir d’une recherche Medline et l’interrogation de deux sites Internet : Toxibase et ASA. Extraction des donnees : Dans la litterature internationale, 42 references ont ete analysees notamment sur la base des elements epidemiologiques qu’elles apportaient. Synthese : Les conclusions de cette analyse ont fait apparaitre que la prevalence de la toxicomanie chez les medecins anesthesistes est probablement de 1 a 2 % sans qu’on puisse determiner si elle est plus elevee que parmi les medecins exercant d’autres specialites medicales. La mortalite des medecins toxicomanes depasse 15 % sur cinq ans. Dans les pays anglo-saxons, les medecins toxicomanes sont pris en charge dans des structures de soins specialisees assurant un taux de reinsertion professionnelle de 60 a 80 % avec toutefois une reorientation des residents vers d’autres specialites. Rien de tel n’existe en France laissant a penser qu’une evaluation du probleme et de son impact actuel serait probablement necessaire.

Neurological complications of epidural anaesthesia are rare, but can be severe. We report the case of a 49-year-old man, with a history of non equilibrated diabetes, who experienced after an epidural anaesthesia for peripheral vascular surgery a polyneuropathy with muscle weakness of the lower extremities associated with a transient urinary incontinence. A spinal compression was excluded by computed tomography and magnetic resonance imaging. Electromyography showed an impaired nervous motor conduction. An aggravation of a pre-existing diabetic and alcoholic polyneuropathy, associated with possible spinal ischaemia of multifactorial origin could be the cause of these complications. This case emphasizes the importance, during preanesthetic assessment of candidates for epidural or spinal anaesthesia, to search for a possible unrecognized neuropathy at risk of aggravation by regional anaesthesia.

In head and neck cancer surgery antibiotic prophylaxis is effective in reducing the incidence of surgical site infections (SSI). However, controversies between antibiotic prophylaxis and curative antibiotic therapy exist, particularly when complex and decaying surgeries are performed in risky underlying conditions, with a risk of persisting salivary effusion in the postoperative period, or in the case of reconstruction with myo-cutaneous flaps. We have performed a systematic review of the literature according to PRISMA recommendations to answer the following questions: indications for antibiotic prophylaxis and curative antibiotic therapy, optimal duration, and choice of antibiotics for prophylaxis in head and neck cancer surgery. Literature analysis allows to conclude that patients undergoing Altemeier classes 2 and 3 surgical procedures should receive perioperative antibiotic prophylaxis restricted to the first 24 postoperative hours. No benefit has been shown with its extension beyond these 24 hours. The most adapted combinations of antibiotics in this setting are "amoxicillin+clavulanic acid" and "clindamycin+gentamicin". However, the level of evidence regarding the most decaying surgeries with high risk of SSI is low, making it necessary to perform new high-powered randomized trials in these patients. Eventually, it should be noted that antibiotic prophylaxis should be an integral part of SSI preventive measures, including application of hygiene measures, and postoperative monitoring of SSI clinical signs.

Nasogastric tube placement (NTP) is no more systematically recommended in patients scheduled for elective colorectal surgery but could be necessary in case of postoperative vomiting. The aim of this study was to determine independent risk factors for NTP after colorectal surgery.We performed an observational study including 290 patients scheduled for elective colorectal surgery included in an enhanced recovery programme: immunonutrition, thoracic epidural analgesia, antiemetic prophylaxis, respiratory physiotherapy, absence of NT and drainage, forced mobilization and oral nutrition. The main outcome was the occurrence of vomiting requiring NTP. Univariate analysis included: age, sex, BMI, American Society of Anesthesiologist Physical Status Classification System (ASA), duration of surgery, epidural analgesia, and mobilization, intraoperative fluid, temperature, laparotomy, use of droperidol, parenteral nutrition, stoma, diabetes, hypertension or coronary disease, COPD, type of surgery. A logistic regression was performed to determine independent risk factors of NTP.Among the 290 patients included, 277 were analyzed. The incidence of NTP was 10.5% (95%CI [7.4-14.6%]). Univariate analysis documented BMI, low temperature in PACU (35°C), ASA scores, duration of surgery and epidural analgesia, rectal and sigmoid resections, diabetes, transfusion, no use of droperidol, duration of mobilization, conversion to laparotomy. Three independent risk factors were associated with NTP: temperature in SSPI35.5°C (OR: 14.49; IC95% [4.52-45.45], P0.0001), BMI21kg/m(2) (8.40; [1.99-35.71], P=0.0038) and lack of postoperative droperidol administration (3.37 [1.02-11.39], P=0.04).After colorectal surgery tolerance to rapid oral feeding is impaired by denutrition and postoperative hypothermia. The combined used of postoperative droperidol should also be considered to avoid postoperative NTP.

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.

Plastic surgery is more and more developing. Facial blocks are adapted to surgical procedures performed in this setting. They are easy to perform and may prolong postoperative analgesia. Facial blocks may be used in ambulatory surgery as a single technique or combined with general anaesthesia or intravenous sedation. After a reminding of facial nerve anatomy, facial and cervical blocks are described with their indications. Guidelines for performance and monitoring are also indicated.

The purpose of benchmarking is to settle improvement processes by comparing the activities to quality standards. The proposed methodology is illustrated by benchmark business cases performed inside medical plants on some items like nosocomial diseases or organization of surgery facilities. Moreover, the authors have built a specific graphic tool, enhanced with balance score numbers and mappings, so that the comparison between different anesthesia-reanimation services, which are willing to start an improvement program, is easy and relevant. This ready-made application is even more accurate as far as detailed tariffs of activities are implemented.

To bring together the most recent evidences concerning the utility and safety of perioperative anti-inflammatory drug use.References were obtained from computerised bibliographic data banks (MeSH terms: NSAIDs, coxibs, steroids, surgery, anaesthesia), followed by manual search.NSAIDs, coxibs and steroids used alone or in association have been demonstrated to be effective for relieving postoperative pain. However, the benefits of perioperative anti-inflammatory drug use may go beyond the postoperative analgesia. In some cases, anti-inflammatory drugs have been shown to decrease the incidence of morphine side-effects, postoperative nausea and vomiting or to improve postoperative recovery. Nevertheless, NSAIDs have been found to be a risk factor of severe postoperative bleeding requiring surgical haemostasis after some surgical procedures. In contrast, coxibs have been shown to promote arterial thrombosis after others surgical procedures.

Nocardiosis is an uncommon infection, which is exceptionally present as a postoperative event. A case of postoperative pulmonary and cerebro-meningeal infection caused by Nocardia otitidiscaviarum after a leg amputation in a diabetic patient is reported. Diagnosis has been delayed and the clinical, radiological and microbiological causes of this delay are assessed from a quality of care management point of view. Recommendations are proposed regarding physicians' role and optimized microbiological procedures for recognition of slowly growing nocardial strains.

Postobstructive pulmonary oedema is a complication after extubation that occurs rarely . It can be associated with haemoptysis. We report two cases of haemoptysis occuring in ASA 1 otherwise healthy patients who underwent uncomplicated anaesthesia. Understanding of the mechanism and prompt treatment lead to rapid recovery of this dramatic complication.

Patient scheduled for infrarenal abdominal aortic aneurysm surgery carries a high risk of cardiac or respiratory comorbidity. To outline the perioperative management for these patients.Review of the literature using MesH Terms "abdominal aortic aneurysm", "anesthesia", "analgesia" "critical care" and/or "surgery" in Medline database.Cardiac preoperative evaluation and management have recently been reviewed. Intermediate and high-risk patients should undergo non-invasive cardiac testing to decide between a preoperative medical strategy (using betablocker+/-statin and aspirin) and an interventional strategy (coronary angioplasty or cardiac surgery). Perioperative myocardial ischaemia should also be investigated by clinical, electrocardiographic and biologic monitoring such as plasmatic troponin Ic dosage. Specific score could also assess the respiratory failure risk preoperatively. Epidural analgesia decreases this risk. There is no evidence that a pharmacological treatment decreases the incidence of acute renal failure after aortic surgery. Endovascular repair is actually recommended for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair.

Patent blue V dye is used to localize the sentinel lymph node during breast and uterine oncological surgery. The case of a grade III anaphylactic reaction related to patent blue dye paracervical injection is described in a 34-year-old woman scheduled for hysterectomy. This complication needs to be rapidly diagnosed to apply adapted supportive treatment.

Addiction behaviours in the anaesthetist population have been recognized as a significant health-related issue and its scope is a matter of concern.A national survey conducted among French anaesthetists consisted of a questionnaire designed to elicit information related to demographics, and work conditions, as well as substance consumption status. The study investigated the following: tobacco, alcohol, tranquillizers-hypnotics, and other agents such as cannabis, cocaine, opiates and anaesthetic agents. Respondents were classified in two categories: (no use and use)-(abuse and dependence). An univariate and multivariate analysis were performed to determine risk factors associated with drug abuse and dependence.3,476 physicians responded to the questionnaire (38.0% response rate); 22.7% were daily tobacco smokers; 10.9% were abuser or dependent to one or more substances other than tobacco i.e. alcohol (59.0%), tranquillizers and hypnotics (41.0%), cannabis (6.3%), opiates (5.5%), and stimulants (1.9%). Sleep disturbances and negative perception of work environment were more frequently reported among addicted anaesthetists.In French anaesthetists, addiction is mainly related to alcohol consumption but includes a broad spectrum of substances. Addicted subjects report issues around work environment that may have contributed to the development of their pathology.

We report two cases of sudden increase in Bispectral Index (BIS) after the injection of low-dose ketamine for the prevention of postoperative hyperalgesia. The two patients were anaesthetised with a continuous infusion of remifentanil associated with propofol for one and isoflurane for the other. Changes in BIS occurred while the two patients were in a stable phase of surgery (beginning of parietal closure and suture of an anastomosis) and had a stable target concentration of anaesthetic agents. No others signs of awakening were observed. The BIS value returned progressively to 40-50 despite no increase in target concentration. None of the patients complained of intra-operative recall.

We report a case of nefopam intoxication in a severely malnourished postoperative intensive care patient with profound hypoprotidemia. Nefopam induced agitation and confusion associated with anticholinergic symptoms such as tremor, hypertonia, mydriasis, and tachycardia. All these symptoms disappeared after withdrawal of the drug. Nefopam should be considered as a possible cause of confusion in postoperative patients.

This study presents a tool including survey questionnaires and a specific data-processing software for the data processing, allowing health care providers to assess the quality of postoperative pain management in surgical wards.Descriptive study.A committee including anesthesiologists, nurses and epidemiologists had elaborated and tested three survey questionnaires to assess patients, nurses and medical staff satisfaction respectively. Specific data processing software was issued out of the final questionnaires. It allowed a quick analysis of items possibly, explaining inadequate postoperative pain management. After this adjustment, this tool was used in three different surgical wards, named A, B, C.The rate of answer (of investigated persons) being over 50%, data resulting from the survey performed in the surgical wards A and B were considered valid. The items which could explain insufficient pain relief were classified into 4 levels: patients assertion (ex: more than 50% of patients experienced persistent postoperative pain); practices evaluation (ex: 42 to 72% health care providers declared being aware of analgesic procedures); behavior's evaluation (ex: 19 to 34% of health care providers considered persistent postoperative pain to be useful for monitoring); and surgical wards potential (ex: 21 to 61% of health care providers took a specific course on pain management). Pros and cons of this tool were carefully examined and subsequent strategies defined.This survey's device should allow health care providers to assess the quality of postoperative pain management in surgical wards. Its validation is currently developed to improve its use, and keep the most performing indicators, showing an adequate postoperative pain management.

The demand for organ transplantation exceeds organ donation in France and refusal to organ donation remains close to 30%. This study analysed risk factors associated with refusal of organ donation.Retrospective study.All potential organ donors registered by the French transplantation agency between 1996 and 1999 were included, excepted those with a contraindication to organ procurement or a logistic problem: 5,911 donors were included.Data analysed were those collected routinely on the French database. A logistic model was used to identify statistically significant factors and a stepwise procedure was performed to identify independent factors linked with refusal.In univariate analysis, age60 years and age13 years, stroke, lack of suicide, localisation in an university hospital and in others regions than the Centre-East of France were associated with a higher refusal rate. Year of harvesting, low level of organ procurement activity were not associated with refusal. In multivariate analysis, factors independently associated with refusal were age60 years [Odds-Ratio (OR) = 1.2)] or age13 years (OR = 1.5), stroke (OR = 1.2), meningitis and cranial tumour (OR = 1.4), suicide (OR = 0.5) and others French regions than Centre-East.The risk factors described should be taking into account when family's members are approached for donation. They represent the interactions between the history of the donors, harvesting organisation, and sociocultural factors.

Resume Les douleurs de membre fantome survenant chez les amputes sont difficiles a traiter. Une remission prolongee de ces douleurs a ete obtenue chez deux patients apres rachianesthesie associant bupivacaine et clonidine, pratiquee a l'occasion d'une revision de moignon. Ces cas cliniques suggerent que les agonistes α2 adrenergiques peuvent bloquer la transmission de douleurs de membre fantome.

Introduction La frequence elevee d’erreurs medicamenteuses (EM) potentiellement graves et surtout evitables justifie une demarche de securisation de l’administration medicamenteuse pour permettre l’administration du Bon medicament a la Bonne dose par la Bonne voie au Bon moment au Bon patient. L’objectif de l’etude est d’evaluer le role de la RMM dans cette demarche. Materiel et methodes Bilan de la methode suivante d’evaluation des pratiques : mise en place d’une politique de service permettant la declaration des EM (pas de sanction, formation a l’analyse systemique, preparation soigneuse de la reunion et eventuelle revue bibliographique) puis presentation des dossiers en RMM. L’analyse de ces EM (a l’origine d’un evenement indesirable EI ou porteur de risque EPR) est collective (participation du personnel medical et non medical), retrospective et systemique ; elle identifie et met en œuvre des actions correctives pour ameliorer l’administration medicamenteuse avec pour referentiels les recommandations de la SFAR « Prevention des erreurs medicamenteuses en anesthesie » [1] et le guide de la Haute Autorite de Sante avec sa « boite a outils » [2] . Resultats D’octobre 2006 a decembre 2013 : 42 reunions, 250 EI et EPR declares, 100 analyses collectivement en reunion dont 19 EM. Repartition de ces EM : 2 erreurs de molecule (ex : atracurium vs midazolam), 3 erreurs de voie (ex : injection intra-arterielle), 11 erreurs de dose. Facteurs favorisants (FF) trouves : lies aux acteurs 6 % (fatigue), a l’equipe 16 % (problemes de communication), aux tâches 36 % (procedures inexistantes, meconnues, pas appliquees, pratiques inappropriees), a l’environnement 29 % (conditionnements similaires, medicament ou dispositif manquant, panne ou defaut de conception de l’equipement), a l’organisation 10 % (interruption des tâches, effectif). Quatre-vingt-quatre pour centde ces FF sont des facteurs humains. L’identification de ces FF a permis la mise en œuvre de mesures correctives directement au niveau du service (redaction de procedures, modifications de pratiques, reorganisation du travail, enseignement) ou au niveau de l’hopital (achat et maintenance de materiel et medicament, formation continue, adaptation des effectifs, participation du responsable de la securite medicamenteuse, declaration ANSM). Discussion Malgre le ressenti culpabilisant et devalorisant de soi pour les acteurs des EM, une strategie de service inspirant confiance rend possible leur declaration spontanee. La methode de conduite de la RMM doit ensuite permettre de faire face a l’erreur et etre a l’origine de mesures utiles et efficaces avec un retour d’experience positif. Dans ces conditions les RMM sont bien un outil de gestion du risque medicamenteux.

To determine the effect of epidural analgesia (EA) on the duration of labour and the mode of delivery.A Medline computerised literature research was conducted from 1989 to 2000 including all the prospective studies comparing EA and systemic analgesia during labour.EA prolongs the first and second stages of labour and increases the rate of instrumental delivery, without neonatal side effects. EA is not responsible for dystocia and caesarean section rate is not increased by this mode of analgesia. The effect of combined spinal-epidural analgesia is comparable to the one of EA on the length of labour and the mode of delivery. Ropivacaine does not appear to be different from bupivacaine in that setting. The benefit of ambulation remains controversial since it does not reduce the incidence of instrumental delivery, compared to conventional EA with similarly diluted local anaesthetic solutions.Pain relief provided by EA combined to modification of obstetric management (amniotomy, oxytocin) does not impair the rate of caesarean section and dystocia.

No epidemiologic study or any other type of evaluation has been performed so far concerning substance abuse among french anaesthetists. We therefore reviewed the English literature to analyse relevant data on this topic.A search for edited manuscripts dedicated to drug addiction in anaesthetists was conducted on Medline and Databases (Toxibase and ASA websites).Forty-two references related to this problem were selected noteworthy based on epidemiologic data provided.1% to 2% of anaesthetists are considered drug addicts in epidemiological studies. Whether the prévalence of drug addiction is higher in anaesthetists compared to other medical specialists remains controversial. Mortality in addict anaesthetists is more than 15% over 5 years. Rehabilitation programs succeed in 60% to 80% of the cases but residents in anaesthesia need to be redirected to another medical specialty.

Neurological complications of epidural anaesthesia are rare, but can be severe. We report the case of a 49-year-old man, with a history of non equilibrated diabetes, who experienced after an epidural anaesthesia for peripheral vascular surgery a polyneuropathy with muscle weakness of the lower extremities associated with a transient urinary incontinence. A spinal compression was excluded by computed tomography and magnetic resonance imaging. Electromyography showed an impaired nervous motor conduction. An aggravation of a pre-existing diabetic and alcoholic polyneuropathy, associated with possible spinal ischaemia of multifactorial origin could be the cause of these complications. This case emphasizes the importance, during preanesthetic assessment of candidates for epidural or spinal anaesthesia, to search for a possible unrecognized neuropathy at risk of aggravation by regional anaesthesia.

We report a case of total spinal anaesthesia which occurred after a lumbar plexus block using a posterior approach. After total hip arthroplasty under general anaesthesia, a lumbar plexus block was performed according to Winnie's landmarks at the L4 interspace using a nerve stimulator. Aspiration test for blood and spinal fluid were both negative, as well as a test dose of 3 mL lidocaine 2%-bupivacaine 0.5%. One minute after the injection of 27 mL of the same mixture, a complete anaesthetic block occurred with hypotension and loss of consciousness requiring intubation and controlled ventilation during 3h30, without sequelae. Lumbar plexus block using a posterior approach must be performed cautiously and a slow and fractionated injection of the full dose is recommended.

The reasons for organ donation acceptance or refusal are still unclear. This study analysed the influence of the circumstances of the conversations with the relatives of brain dead patients on their consent for organ donation.Prospective study.The analysis included 41 questionnaires collected over nine months in one organ harvesting centre and focusing on the circumstances of death, the conditions of the conversations and the reasons for acceptance or refusal.Questionnaire filled in by the physicians after the interviews of the relatives of brain dead patients.The refusal rate was higher (54 vs 21%) when only one physician participated in the conversation, when more than two relatives had to decide (42 vs 24%), when conversations took place during night or when the request for organ donation followed immediately the announcement of death (43 vs 20%). Most often the relatives gave their decision within minutes following the request.The circumstances of conversation with families play an essential role in their decision-making. A written guideline implementation for these conversations would probably be beneficial for the decisions of families in favour of organ donation.

A 47-year-old woman suffered from a pharyngeal cancer causing pain only poorly relieved by high doses of oral morphine. Oral administration was switched to the intracerebroventricular (ICV) route but pain relief was only transient despite a daily dosage up to 1.5 mg of morphine. Finally an effective pain relief was achieved with increasing doses of clonidine (5 to 30 micrograms) in combination with morphine (1.5 mg) by ICV route. Neither arterial hypotension nor sedation occurred and the patient recovered transiently a better quality of life.

In order to assess the quality of sleep in surgical patients the amount of self-rated postoperative insomnia and its predisposing factors, we conducted a three-fold questionnaire * survey in 176 consecutive patients undergoing elective orthopaedic, vascular or abdominal surgery. The first questionnaire was completed the day preceding surgery, the second at the day of discharge and the third two weeks later. This survey concerned the patient's general status, his usual sleep profile and factors which could interfere with sleep (hypnotics, pain, environmental factors) throughout the study period. It allowed quantification of these parameters and the assessment of their time-course. Perioperative insomnia appeared to be a long-lasting phenomenon which persisted after discharge. Factor analysis and multiple regression models showed that postoperative, self-rated insomnia was multifactorial and mainly explained by the amount of postoperative pain (p = 0.035).

The benefits of transoesophageal echocardiography (TOE) were assessed prospectively in intensive care patients. The doctors carrying out TOE were not the same as those who ordered it. TOE was performed in 32 patients, all of whom but one were intubated and artificially ventilated, to elucidate the cause of circulatory shock, or to search for valvular vegetations or an intracardiac mass. TOE confirmed the diagnosis previously obtained with pulmonary arterial catheterization (10 patients), transthoracic echocardiography (3 patients) or ventriculography (1 patient) in 54% of cases. In 28% of cases, TOE invalidated the suspected diagnosis, and, in the remaining 28% of patients, TOE invalidated provided a previously unsuspected diagnosis. TOE was particularly useful in confirming the presence of valvular vegetations, endocarditis, or intracardiac thrombi, and to assess left ventricular function and preload in patients in shock. Like others, this study confirms the benefits of TOE in the intensive care setting.

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) (p0.05). 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.

A case is reported of a patient with a traumatic aneurysm of the intracranial part of the carotid artery occurring after a traffic accident. The patient was admitted in coma (Glasgow score 5), and presented with a depressed fracture of the frontal and parietal bones, a fracture of the left petrous pyramid and of the left anterior clinoid process, as well as of the right tympanic bone and temporomandibular joint. The borders of the left carotid canal seemed unaltered. Despite the lack of localised neurological signs, cervical and transcranial Doppler ultrasonography was carried out. Intracranial carotid blood flow was found to be altered on both sides. Angiography showed a false carotid aneurysm on the left side (carotid siphon portion C3), and a moderate irregular stenosis of the C2 part on the right. There were no brain lesions on the CT scan. Prophylactic treatment with heparin was started. The patient recovered normal consciousness within a fortnight. The false aneurysm increased in volume and was treated by embolisation. Flow speeds in the carotid siphons also returned to normal. The usefulness of routine screening of patients with petrous bone fractures with Doppler ultrasound is discussed.

Eleven anaesthesia ventilators were instrumentally tested under various conditions. They included: Excel and Modulus II Plus (Ohmeda); 710 and Servo anaesthesia circle 985 (Siemens); Jollytronic (Soxil) and Elsa (Engström); SA2 and Cicero (Dräger); ABT 4,300 (Kontron); Monnal A and the prototype Alys (Taema). The test circuit comprised a two compartment model lung, a pneumotachograph, a pressure gauge in the "airway". The volume was calculated as the integral of flow rate. Each machine was calibrated by the firms' technicians. Before each test, the pneumotachograph was calibrated using a 11 air syringe and the pressure gauge with a 5 cm water column. Each machine ventilated the model lung for 30 min before starting the tests. There were five tests: 1) reliability of the machine's spirometer, 2) reliability of the ventilation rate, 3) reliability of pressure measurements, 4) effect of increasing fresh gas flow on spirometry, 5) effect of increasing downstream resistances. In usual simulated ventilatory conditions, all the machines accurately delivered the setted ventilation and spirometric measurements were with minimal error only. Several ventilators (SA2, Excel, 710, Elsa, ABT 4,300) did not succeed in maintaining their performances when compliance was strongly decreased or resistance of the test lung notably increased. Resistance in the circuit during simulated spontaneous ventilation was3.6 cmH2O.l-1.s-1. Increasing fresh gas flow raised the minute volume delivered in six ventilators. It is concluded that, during extreme ventilatory conditions, the inspired volume must be adjusted so as to maintain the inspired tidal volume. However, ventilators which increase inspiratory time in response to an increased mechanical load cannot be adjusted by this way.

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.