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Highlights L’épidémie de SARS-CoV-2 a contraint les établissements hospitaliers à augmenter le nombre d’unités de soins critiques Les pharmacies hospitalières ont dû répondre dans des délais très courts aux besoins en médicaments et dispositifs médicaux. La présence de préparateurs affectés dans les unités de soins critiques à la gestion des produits pharmaceutiques en étroite collaboration avec les médecins et le personnel infirmier depuis plusieurs années a été un facteur déterminant dans la conduite des opérations. Le calcul quotidien des quantités notamment de curares consommées par patient a constitué un élément clé pour ajuster les commandes et les livraisons et préparer les changements de spécialités imposés par les ruptures d’approvisionnement. Cet épisode de crise légitime la question de l’extension de l’ouverture de la pharmacie d’un centre hospitalo-universitaire en équipe complète 365 jours par an., Le circuit du médicament hospitalier le plus sûr est la dispensation journalière individuelle nominative automatisée assurée par la pharmacie. Depuis plusieurs années nous essayons de convaincre les décideurs hospitaliers de l’implanter dans notre établissement. En attendant, pour pallier les risques d’erreurs médicamenteuses encourus par les patients et les soignants, nous avons constitué plusieurs équipes de travail au sein des unités de soins. Ces équipes sont constituées d’un pharmacien et d’un ou deux préparateurs en pharmacie hospitalière qui assurent notamment la gestion des armoires à pharmacie des unités de soins. La collaboration étroite avec médecins et personnel infirmier développée au fil des années a été un élément favorable déterminant lorsqu’il a fallu doter en médicaments et en dispositifs médicaux stériles (DMS) les nouvelles unités de soins critiques face à l’afflux de patients contaminés par le SARS-CoV2. Le suivi quotidien des médicaments consommés par patient, particulièrement les curares, et des DMS en rupture d’approvisionnement a été un élément clé de la gestion des stocks et des changements de principes actifs, de conditionnements et/ou de références de matériel. Les faits relatés donnent du poids au rapport Claris qui souligne les effets positifs en termes de qualité et de sécurité de prise en charge des patients du travail des PPH et pharmaciens dans les unités de soins. Ils soulignent par ailleurs les dangers auxquels sont exposés patients et soignants samedi, dimanche et jours fériés quand la pharmacie est fermée. Ils légitiment la question de l’extension de l’ouverture de la pharmacie en équipe complète 365 jours par an.

Pain assessment is an important activity in nursing care. Postanaesthesia recovery rooms are specialised care units. Pain assessment must form part of a global approach, beyond an objective of care. The nurse plays a key role from the reception of the patient through to their transfer to the ward.

A hepatectomy is a surgical procedure involving a high risk of haemorrhage and an operation lasting several hours. It is for this reason that a period of monitoring by trained nursing staff in the postanaesthetic recovery room is essential until the vital functions stabilise and a protocol for effective analgesia is implemented.

Pulse pressure variation (ΔPP) has been demonstrated to be an accurate dynamic parameter to predict fluid responsiveness. However, the impact of different ventilator modes on this parameter is unknown. We compared ΔPP values calculated alternatively during pressure- and volume-controlled ventilation.Double-blind randomized study, cross-over design.Patients in intensive care unit after a cardiac surgery.Patients were ventilated alternatively in both ventilator modes (according to the randomization): volume-controlled ventilation (VVC) and pressure-controlled ventilation (VPC). Other parameters of ventilation were identical. ΔPP values were calculated for each patient in both ventilator modes.Among the 26 patients analyzed, mean ΔPP value was de 14.0±7.3% in VVC and 11.8±6.2% in VPC (P0,0001). On Bland-Altman representation, mean bias was +2.2±2.3% and inferior and superior limits of agreement were respectively -2.3 and 6.7%. Arterial blood pressure and central venous pressure were not modified.ΔPP values obtained with both ventilator modes were not interchangeable. On average, ΔPP decreases by more than two points in the passage VVC to VPC for a given patient, all others things being equal.

At Necker-Enfants malades hospital, the presence of the parents alongside the child during the immediate postoperative period has been allowed and encouraged for a number of years. In order to standardise the practices in terms of allowing parents to enter post-anaesthetic recovery rooms, nurses have drawn up a procedure to follow. In parallel, a study and a satisfaction survey have been carried out in order to measure the benefits of this approach for parents and for the child undergoing the operation.

Catheter-related bladder discomfort (CRBD) is an unrecognized clinical event. Symptoms of CRBD secondary to an indwelling urinary catheter mimic those of an overactive bladder, i.e. urinary frequency and urgency with or without urge incontinence. Stimulation of muscarinic receptors located in the bladder wall by the catheter is the triggering factor. Postoperative pain may be increased by the CRBD. Antimuscarinic drugs, as oxybutynin, are today the main treatment. Further studies are warranted to confirm efficacy of ketamine, tramadol and gabapentin in this situation.

Control of residual muscle paralysis and hypothermia reduce postoperative complications rate. Short context sensitive half life anaesthetic agents allow a better adjustment of anaesthesia depth according to surgical requirement and a safe early extubation. Using a large clinical database, impact of these three strategies was assessed on clinical criteria such as use of neostigmine in postanaesthesia care unit (PACU), temperature, sedation score at the arrival into PACU and mechanical ventilation weaning.This is a retrospective study on two separated periods. Since 2001, clinical events are entered into the database during and after anaesthesia in the same file. Agreement of anaesthesia staff to these strategies was assessed by the proportion of patients receiving modern anaesthetic agents (desflurane, sevoflurane and remifentanil) and the use of warming devices. Clinical impact was assessed by the number of patients receiving neostigmine in PACU, sedation score and temperature at the arrival in PACU and number of patients with mechanical ventilation in PACU.Between the two periods (12,033 and 11,805 patients, respectively), use of sevoflurane, desflurane and remifentanil markedly increased, as well as the use of warming devices. Number of patients with neuromuscular reversal in PACU decreased from 73 to 11 and sedation score improved dramatically. Incidence of postoperative ventilation in PACU decreased from 1.1% (n=132) to 0.2% (n=30). Incidence of postoperative hypothermia was not changed during the two periods but incidence of hypothermia in the mechanically ventilated patient increased from 34.1 to 46.6%. Length of stay in PACU decreased from 122 to 114 minutes (p0.05).Implementation of new intraoperative protocols induced major effects on postoperative clinical parameters and especially postoperative mechanical ventilation. Failure of our hypothermia prevention associated with a fast return of consciousness lead to wean from mechanical ventilation hypothermic patients. Risks of this strategy were not estimated.

As the susceptibility of staphylococcal strains to glycopeptides rises, it is becoming necessary to increase vancomycin dosages.To evaluate an administration protocol for vancomycin using continuous infusion with a loading dose of 30 mg/kg followed by 30 mg/kg per 24h in intensive care patients presenting creatinine clearance (CLc) greater than 50.A total of 22 patients were included in the study. Serum vancomycin concentrations after 24h (C24h) ranged from 25 to 30 mg/l in seven of 14 patients with CLc less than 120 ml/min (50 %), compared with three patients (21 %) with C24h greater than 35 mg/l and four patients (29 %) with C24 h less than 25 mg/l. However, C24h was less than 20mg/l for the eight patients with CLc greater or equal to 120 ml/min. Bacteriological data was available for eight of the 14 patients with CLc less than 120 ml/min, and in these eight patients, the C24h/MIC was greater or equal to 8; seven of these patients had an AUC/MIC greater or equal to 350.Assay of serum vancomycin concentrations after 24h of treatment is necessary to enable rapid adjustment of vancomycin concentration in order to improve therapeutic efficacy or avoid nephrotoxicity.

Iatrogenic pathology is currently a serious problem. Intensive care units (ICU) are wards with a high risk of occurrence of adverse events (AE) related to the care and medical errors. The incidence of AE in ICU varies from 3 to 31% according to the publications. These variations are mainly due to the methodology of data collection. The latter is essential. The indicators must be standardized (consensual definitions), and easily collected. The method of collection must be ideally prospective, nonpunitive, confidential, independent within a compliant team, and realized with the participation of various actors not only of the unit but also external (biologists, pharmacists). The risk factors of AE in ICU are known: old age and high severity scores at admission, with medical and nurse workload more important. AE are associated with an increased patients' morbidity in ICU with no evident causality. The over cost related to AE in ICU was quantified to 3961 dollars in the United States. The mortality of patients with an AE is higher but no study showed to date that AE constituted an independent risk factor of mortality in ICU. Some AE are preventable (from 28 to 84% according to studies). Therefore, the implementation of procedures of security (PS) is capital. Many methods often easy to implement exist such as in care, structural and managerial procedures. The development of a safety culture in hospitals and other delivery care settings is essential. It is the first essential step in a better comprehension of the health care professionals and the public opinion.

To study the assessment of hygiene practices in anaesthesia in Lorraine between 1998 and 2007, after recommendations from the French Society of Anaesthesia and Reanimation (SFAR) in December 1997, and different local actions.Two surveys performed at a nine-year interval in Lorraine hospitals.Questionnaires about risk infection management and hygiene practices were sent by post to all anaesthetists, nurse anaesthetists and recovery room nurses in 1998 (n=279) and in 2007 (n=259).Between the two surveys multidrug-resistant bacteria signalling, movements of the staff in operating rooms, septic isolation protocol and management of single-use disposable anaesthesia material have been improved (p0.05). Central venous catheters are less performed in recovery rooms and rings wearing decreased by 16% (p0.05). Wearing of nonsterile gloves for peripheral venous catheter and intubation is not generalized (p0.05). About half of the hospitals have cleanup procedures of anaesthesia furniture. Washing of hands by anaesthesia staff is not sometimes respected but it's more frequent for medicine preparation and between two operations. A good skin disinfection (cleaning - rinsing - drying - antiseptic) is more recurrent in 2007 (61.4%) than in 1998 (41.9%) for arterial catheter. Wearing of glasses for intubation is each times rare, about 15%.Hygiene practices in anaesthesia in Lorraine have been improved between the two surveys by recommendations from the Sfar and the work of the Antenne Régional de Lorraine (audits, manuals, formations). Promising progress has been made but some points must still be worked on.

The aim of this study was to determine the risk factors for postoperative infection after craniotomy, a threat for the vital prognosis, in order to define specific prevention measures.An open prospective study was made on all adult patients undergoing craniotomy and followed 30 days postoperatively. The infections were defined according to CDCA criteria. The parameters studied were: age, sex, ASA and Glasgow scores, neurosurgical history, the type, the moment and the surface of shaving, antibioprophylaxis, and the type and duration of surgery as well as its emergency level.One hundred and seventy patients were included. Thirty presented with an infection (17.6%), nine with a skull infection, 13 with meningitis, three with empyema, and two with osteitis. The risk factors identified thanks to a univariate analysis were the emergency level of surgery (P0.01), duration of surgery200 min, and duration of stay in ICU72 h (P0.02).

Early administration of analgesics, generally before awakening from general anesthesia is useful to improve the patient's comfort in the post-anesthesia care unit (PACU). Multimodal analgesia includes administration of several analgesics from different pharmacological classes but in almost every combination, morphine or one of its derivatives is included. In the PACU, morphine is titrated using the intravenous route to obtain adequate and rapid pain relief. Analgesics are administered orally as soon as possible and in the vast majority of cases, immediate postoperative administration can be performed orally. After minor surgery (for example: diagnostic or operative laparoscopy) often performed in out-patients, a combination of acetaminophen and of a non-steroidal anti-inflammatory drug with or without an oral preparation of morphine is efficient and safe. Intraperitoneal administration of a local anesthetic can be a useful addition. When the postoperative surgical stress is expected to be of moderate intensity (for example: hysterectomy), the same combinations can be used but are initially administered intravenously. Nefopam, which is available only by intravenous administration in France, can be safely added. Morphine is often applied using a patient-controlled analgesia device (PCA). After major surgery (especially after radical surgery for malignant disease), intrathecal or epidural analgesia, using a local anesthetic and an opioid is extremely efficient and is combined with other analgesics. Finally, because the affective dimension is extremely important after gynecologic surgery (especially in mutilating interventions), psychologic preparation, patient information and communication are essential components of care.

The relative contribution of anesthesia costs to total perioperative costs is not known precisely. The goal of this prospective study was to measure the proportion of anesthesia costs relative to total hospital costs of elective laparoscopic cholecystectomy (LC) for in-patients.With Institutional approval, the total hospital costs of elective LC for 62 ASA I-III patients were analyzed. All direct and indirect variable costs, including salaries of anesthesia and surgery teams, were obtained for each patient. Data are expressed as mean +/- SEM.Intraoperative anesthesia costs as a percentage of the total hospital costs equaled 10.5 +/- 0.3%. Postanesthesia care unit (PACU) cost was 3.1 +/- 0.2%. The largest hospital cost category was the operating room with 37.4 +/- 0.6%. The costs attributed to the ward equaled 31.3 +/- 3%. Other costs were generated by radiology (6.2 +/- 1.1%), laboratory (5.4 +/- 0.7%), admission unit (3.4 +/- 0.2%), pharmacy (2.0 +/- 0.4%) and administration (0.7 +/- 0.1%).Even if salaries are included, anesthesia and PACU costs (13.6%) represent a small portion only of total hospital costs. Cost savings thus may result from improving operating room efficiency and shortening of hospitalisation rather than programs aiming at lowering anesthesia costs.

We report a case of postoperative apnoea in the recovery room, 25 minutes after tracheal extubation, in a fully awake patient. This event occurred after flushing of an obstructed IV line into which remifentanil had been injected through a 3-way stopcock during anaesthesia. The means for prevention of such an adverse event are discussed.

A. baumannii is a multiresistant bacteria which is recognised as responsible for nosocomial infections and hospital outbreaks. The control of these outbreaks depends on the strain's typing and on the fight's policy against nosocomial infections. An outbreak of A. baumannii is occurred to patients who were hospitalized in Centre Hospitalier de Versailles. To investigate this outbreak, we have determined the biotype (Bouvet's method), the succeptibility pattern (disk diffusion and agar dilution results were analysed with the hierarchical classification and main component analysis) and the total DNA macrorestriction pattern (Pulse Field Gel Electrophoresis using SmaI restriction enzyme). A risk factors for A. baumannii acquisition were delineated in case-control study. During 2 years, 38 patients have been infected or colonized to A. baumannii. Thirty two patients were hospitalized in ICU. We studied 38 non repetitive clinical isolates and 9 strains of the patient's rooms. Four biotypes were defined by the Bouvet's typing method. Fourteen groups were obtained when succeptibility results were analysed with the hierarchical classification and 6 with the main composant analysis. The molecular typing permit us to define 4 epidemic and 6 sporadic strains. All the epidemic strains were isolated on ICU hospitalized patients. Our study has shown wide contamination in patient's rooms (Water tap, dry surfaces, patient's mattresses...). Environmental objects have been a major risk factor for A. baumannii acquisition. The control of this outbreak has been possible by application of hygienic measures (hands washing, isolment, meticulous cleaning of the ICU and environmental controls). No new case is occurred in the last year. Typing methods and case-control study are necessary to investigate cross-infections and take efficient measures against these outbreaks.

Epidemiologic supervision of P. aeruginosa infections is a daily care for microbiologists. The aim of this study is to evaluate quantitative antibiogram, which compare strains by calculation of euclidian distances from inhibition zone diameters on agar, compared with pulse field gel electrophoresis (PFGE) results. 53 isolates of P. aeruginosa obtained from bronchial secretions of 26 patients in intensive care unit are typed by conventional disk diffusion test on agar with 11 usual antibiotics. Dendrogram of euclidian distances is performed by Taxotron computer program (P.A.D. Grimont, Institute Pasteur, Paris); results are compared with 53 PFGE patterns after restriction with Spe I (Genepath system, BIO-RAD). Quantitative antibiogram has a high discriminatory power for beta-lactamin resistant strains: 27 isolates from 11 patients clustered in 5 types where PFGE discerned 5 patterns. The discriminatory power is low for beta-lactamin sensible strains: 26 isolates from 15 patients clustered in 8 types where PFGE discerned 19 patterns, but serotyping method combined with quantitative antibiogram restore a high disriminatory power for beta-lactamin sensible strains.

Local or block anesthesia can be used satisfactorily in many implant procedures. However, when advanced implant techniques or pre-prosthetic reconstruction surgery of the maxillofacial bones are required, local or regional anesthesia is insufficient. The "day-hospital" concept is a rational approach which meets the requirements for anesthesia and deep sedation with criteria for patient safety and comfort while guaranteeing optimal operating conditions. Intravenous sedation, both "conscious" and "deep" sedation, is a very well adapted form of anesthesia for implant recipients. Local or block anesthesia is enhanced or reinforced prior to surgery by the intravenous administration of a sedative and anxiolytic agent (single-drug concept), such as a benzodiazepine, associated or not with a morphinomimetic agent and an antihistaminic substance (multiple-drug concept). The main goal is to maintain spontaneous respiration while obtaining postoperative amnesia of the entire procedure. Mandatory use of a pulse oximeter has greatly contributed to improved safety of intravenous sedation, essentially indicated for operations not lasting more than 2 and a half hours in patients in good general health (scoring 1 or 2 in the American Society of Anesthesiology (ASA) classification) and with a low risk of postoperative complications. This concept requires an adapted technical facility. The operating theatre should have all the equipment necessary for cardiovascular, neurological and respiratory emergency care. The postoperative recovery room should also be equipped with cardiovascular monitoring devices and be able to accommodate an intensive care unit. Under these strict rules, short duration surgical procedures (150') can be performed : 1) with the best conditions of medical safety, 2) with improved operating conditions for the implant surgeon (the patient responds immediately to vocal orders when necessary) while asepsis is maintained as easily as with general anesthesia, 3) with better conditions for postoperative care and patient comfort (the anesthetist is continuously present). 4) better psychological conditions for the patient who will be discharged the same day, 5) with total amnesia of the entire surgical procedure, 6) elimination of a usually disproportionately long hospitalization. Day hospitalization also helps contain health care costs by cutting out the need for overnight care and accommodation. We underline the safety of current intravenous sedation techniques and present two series of data related to the use of this technique by an anesthetist and an operating surgeon in a day hospital from 1986 to 1995.

Because of the increasing role of post-anaesthesia care in anaesthetic activity, the explicative value of various factors on post-anaesthesia length of stay (POLS) was tested.Retrospective study.Population of 38,655 patients admitted to the post-anaesthesia care unit (PACU) between 1990 and 1994.Multivariate analysis (semiparametric Cox model) of POLS.Overall 71% of the patients stayed less than four hours in PACU. Average POLS did not vary with years. Eleven variables were related to POLS, with an odds-ratio (OR) between 0.75 and 0.77 (negative link) or between 1.22 and 2.77 (positive link). A comparison of the OR for years 1990 to 1994 indicated major variations for the following three variables: neurosurgery, mechanical ventilation in PACU, low occupancy rate in the PACU at the time of discharge.POLS are linked with various factors whose changes in explicative value can be analysed chronologically. However, other methods remain necessary in order to evaluate the impact of organisational modifications, as the introduction of objective criteria for discharge.

To assess the direct cost of a stay in a postanaesthesia care unit (PACU).Standard cost study based on information gathered from staff and suppliers in accordance with government regulations and recommendations. Results reviewed by a group of anaesthesists. TYPE OF PACU: PACU working in ideal conditions with optimal safety conditions for and accommodation surgical patients).Estimation of three cost components: 1) depreciation and maintenance costs of equipment, 2) physician and other staff wages, and 3) variable costs such as drugs and disposable devices. We computed an annual budget for three PACU which was defined according to size (4, 8 or 12 beds) and working hours.Fixed annual costs (staff and equipment) were 1,134,938 FF for a 4 bed room: 3,820,339 FF for an 8 bed room: and 6,481,792 FF for a 12 bed room. Variable costs per stay were 75,43 FF. The cost of a stay in an 8 bed PACU based on a rate of 3,500 stays per year therefore was 1,167 FF (87.0% for staff, 6.6% for equipment, 6.4% for variable costs).

Recent surveys, especially in Britain and in Finland, have completed and updated a survey on anaesthesia-related morbidity and mortality that was carried out under the auspices of the French institute for health and medical research a decade ago. Severity of the patient's condition remains the key factor, along with the extent of surgery, while the improvement of safety conditions in anaesthesia through standards and recommendations is beginning to produce results.

This study reports the results of a survey of post-anaesthesia recovery rooms (PARR) in French public University Hospitals (UH), and in those of the "Ile de France" (IdFH) area. The study, carried out between the 2nd and 8th of April 1990, aimed to identify the place where patients recovered from anaesthesia, and the personnel and monitoring equipment available in these places. 90% of 55 departments of anaesthesia and intensive care in University Hospitals and 94% of 34 departments in "Ile de France" Hospitals responded. A total number of 20,567 patients was collected, with 10,027 from University Hospitals. Of the latter, 31.4% recovered in the operating room or in the anaesthetic room itself; 7.5% were directly transferred to an intensive care unit (ICU), and 61.1% (10,397) were admitted to a PARR. However, 2,460 of those admitted to such a PARR were in fact admitted to a PARR without any permanent nursing staff. Overall, 45.8% of the patients were not admitted to a PARR where adequate care by nurses was available. Of the 3,540 patients anaesthetized in "Ile de France" Hospitals, 3.1% were transferred to an ICU, 25% were not admitted to a PARR, and the remaining 71.7% were. However, 35% of those admitted to a PARR were admitted to a PARR without any permanent nursing staff. Therefore 50.1% of patients anaesthetized in the "Ile de France" Hospitals did not benefit from adequate post-anaesthetic supervision. In 82% of the patients anaesthetized in University Hospitals, the lowest rates of admission to a PARR were found in patients undergoing gastrointestinal endoscopy (GIE), and ENT, ophthalmological or stomatological surgical procedures. After anaesthesia for GIE, 69% of patients recovered at the anaesthetic post and 12% were admitted to a PARR without any permanent nursing staff. In ENT-Ophthalmology-Stomatology, Gynaecology and Obstetrics, and Radiology departments, 56%, 69% and 69% of patients, respectively, recovered in the anaesthetic room or in a PARR without any permanent staff, or, for the Radiology and Obstetrics departments, sent straight back to their room. Similar results were obtained with the patients in the "Ile de France" Hospitals. Nurses were not always present in 37% and 24% of PARR in University and "Ile de France" Hospitals respectively. In the PARR, there were three ECG monitors for 4 beds, and one pulse oximeter for seven beds. It seems therefore that, despite several ministerial recommendations, not all anaesthetized patients are admitted to a recovery room after their anaesthetic.