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Background: The conventional two-step process for surgical procedures - surgical followed by anaesthetic consultation - may not adequately address the needs of complex cases involving high-risk patients or procedures, leading to increased risks of adverse events. Although surgical team meetings (STM) and multidisciplinary team meetings (MDTM) were implemented many years ago, anaesthesia team meetings (ATM) have recently emerged as potential solutions to enhance perioperative management., Purpose: We aim to systematically review and summarize the existing literature that reflects the main theoretical approaches, practices, effects, and clinical relevance of preoperative team meetings - with specific consideration to preoperative ATM - in managing difficult cases., Methods: We performed a narrative review of the literature (1980-2024) to identify studies focusing on the practice and the impact of preoperative meetings on patient outcomes, compliance with treatment plans, and teamwork quality. We provide here a qualitative synthesis of the findings., Results: Fourteen studies were identified: 11 consider preoperative multidisciplinary team meeting (MDTM), 2 consider preoperative surgical team meeting (STM), and only one anaesthesia team meeting (ATM)., Conclusions: There is currently not enough robust evidence that preoperative team meetings clearly improve hard patient's outcome parameters. And the place for ATM does not appear to have been studied to date. There is a need for well-designed studies to explore the impact of preoperative ATM on clinical practice improvement, quality of care, and patient outcomes., (Copyright © 2024 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: Central venous catheter (CVC) insertion using simulation is an essential skill for anesthesiologists. Simulation training is an effective mean to master this skill. Given the large number of residents and the limited duration of training sessions, the active practice time is limited and residents remain observers of their colleagues for much of the session. To improve learning during observation periods, the use of an observer tool (OT) has been advocated but its educational effectiveness is not well defined., Methods: Incoming anesthesia residents were randomized to use an OT (i.e. procedural skill-based checklist) (OT+) or not (OT-) when observing other residents during a simulation bootcamp. The primary outcome was a composite score (total 60 points) evaluating CVC procedural skills rated immediately after the training. This score covers theoretical knowledge explored by multiple choice questions (MCQs) (/20), perceived improvement in knowledge and skills (/20), perceived impact on future professional life (/10) and satisfaction (/10). Measurements were repeated 1 month later. Residents in each group recorded the number of CVCs placed and their clinical outcomes (attempts, complications) during the first month of their clinical rotation using a logbook., Results: Immediately after training, the composite score was similar between the two groups: 45.3 ± 4.2 (OT+, n = 49) and 44.4 ± 4.8 (OT-, n = 42) (p = 0.323). Analysis of sub-items also showed no difference. Results at 1 month were not different between groups. Analysis of the logbook showed no difference between groups. No serious complications were reported., Conclusions: The use of a procedural task-based OT by incoming anesthesia residents and used during CVC insertion simulation training was not associated with better learning outcomes, neither immediately after the session nor when re-evaluated 1 month later. The training at least once on simulator of all residents could limit the impact of OT. Further studies are necessary to define the place of OT in simulation training., (© 2023. The Author(s).)

Phenomenon : The urgency of having fair and trustworthy competency-based assessment in medical training is growing. Simulation is increasingly recognized as a potent method for building and assessing applied competencies. The growing use of simulation and its application in summative assessment calls for comprehensive and rigorously designed programs. Defining the current baseline of what is available and feasible is a crucial first step. This paper uses anesthesia and intensive care (AIC) in France as a case study in how to document this baseline. Approach : An IRB-approved, online anonymous closed survey was submitted to AIC residency program directors and AIC simulation program directors in France from January to February 2021. The researcher-developed survey consisted of 65 questions across five sections: centers' characteristics, curricular characteristics, courses' characteristics, instructors' characteristics, and simulation perceptions and perspectives. Findings : The participation rate was 31/31 (100%) with 29 centers affiliated with a university hospital. All centers had AIC simulation activities. Resident training was structured in 94% of centers. Simulation uses were training (100%), research and development (61%), procedural or organizational testing (42%), and summative assessment (13%). Interprofessional full-scale simulation training existed in 90% of centers. Procedural training on simulators prior to clinical patients' care was performed "always" in 16%, "most often" in 45%, "sometimes" in 29% and "rarely" or "not" in 10% of centers. Simulated patients were used in 61% of centers. Main themes were identified for procedural skills, full-scale and simulated patient simulation training. Simulation activity was perceived as increasing in 68% of centers. Centers expressed a desire to participate in developing and using a national common AIC simulation program. Insights : Based on our findings in AIC, we demonstrated a baseline description of nationwide simulation activities. We now have a clearer perspective on a decentralized approach in which individual institutions or regional consortia conduct simulation for a discipline in a relatively homogeneous way, suggesting the feasibility for national guidelines. This approach provides useful clues for AIC and other disciplines to develop a comprehensive and meaningful program matching existing expectations and closing the identified gaps.

Introduction: The growing number of learners implies that all of them cannot play an active role during high-fidelity scenarios. Studies suggest a positive educational value when learners are observers only, but it remains uncertain whether learning outcomes might be improved by using an observer tool (OT)., Methods: Eighty-nine anesthesia residents were randomized to use an OT (n = 44, OT+; based on a cognitive aid) or not (n = 45, OT-) when not role-playing. The main outcome parameter was the learning outcomes assessed by comparing the change (before-after) in the response score to a questionnaire dedicated to medical knowledge obtained in the OT+ and OT- groups. The impact of using the OT was also assessed by measuring the perceived stress level and the change of the Anesthetists' Non-Technical Skill items values., Results: At the end of the session, the mean medical knowledge score (mean ± SD) was higher in the OT+ group than in the OT- group (11.4 ± 2.7 vs. 9.6 ± 2.4, respectively, P = 0.0008). The mean Anesthetists' Non-Technical Skill score and level of stress perceived did not differ between groups. Trainees rated similarly the learning value and satisfaction related to the simulation course., Conclusions: This study suggests that observing high-fidelity simulation scenarios using an OT based on a cognitive aid increases the medical knowledge gain when compared with that seen in passive observers. This study suggests that the use of an OT improves the educational value of simulation., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Society for Simulation in Healthcare.)

Introduction: Clinical outcomes and critical care utilisation associated with Coronavirus Disease 2019 (COVID-19) in obstetric patients remain limited particularly in relation to severe cases., Methods: A retrospective multicentre cohort study was conducted during the first wave of COVID-19 in France in 18 tertiary referral maternity units. Consecutive women with confirmed or suspected COVID-19 during pregnancy or the delivery hospitalisation were included between March and July 2020 (17-week period). We report clinical, obstetrical and anaesthetic outcomes of pregnant women with COVID-19 and report the prevalence of severe forms and risk factors for respiratory support in this cohort., Results: There were 126 included cases; RT-PCR testing occurred in 82 cases, of which 64 (78%) had a positive test. The caesarean section rate was 52%, and preterm delivery (< 37 weeks) rate was 40%. Neuraxial anaesthesia was performed in 108 (86%) cases with an increasing proportion compared to general anaesthesia over time (p < 0.0002). Twenty-eight cases received oxygen supplementation (nasal oxygen therapy or mechanical ventilation); the SOFAresp score was associated with gestational age at the time of COVID-19 presentation (p = 0.0036) and at delivery (p < 0.0001). Postpartum intensive care unit (ICU) admission occurred in 21 cases (17%) with 17 (13%) receiving invasive or non-invasive ventilation. Pre-delivery factors associated with postpartum ventilation were oxygen support, oxygen saturation and haemoglobin levels., Conclusion: In our cohort, COVID-19 was associated with significant maternal morbidity resulting in high ICU admission rates (17%) and invasive or non-invasive ventilation utilisation (10%)., (Copyright © 2021 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Importance: The use of cricoid pressure (Sellick maneuver) during rapid sequence induction (RSI) of anesthesia remains controversial in the absence of a large randomized trial., Objective: To test the hypothesis that the incidence of pulmonary aspiration is not increased when cricoid pressure is not performed., Design, Setting, and Participants: Randomized, double-blind, noninferiority trial conducted in 10 academic centers. Patients undergoing anesthesia with RSI were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge (last follow-up, February 8, 2017)., Interventions: Patients were assigned to a cricoid pressure (Sellick group) or a sham procedure group., Main Outcomes and Measures: Primary end point was the incidence of pulmonary aspiration (at the glottis level during laryngoscopy or by tracheal aspiration after intubation). It was hypothesized that the sham procedure would not be inferior to the cricoid pressure. The secondary end points were related to pulmonary aspiration, difficult tracheal intubation, and traumatic complications owing to the tracheal intubation or cricoid pressure., Results: Of 3472 patients randomized, mean (SD) age was 51 (19) years and 1777 (51%) were men. The primary end point, pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group. The upper limit of the 1-sided 95% CI of relative risk was 2.00, exceeding 1.50, failing to demonstrate noninferiority (P = .14). The risk difference was -0.06% (2-sided 95% CI, -0.57 to 0.42) in the intent-to-treat population and -0.06% (2-sided 95% CI, -0.56 to 0.43) in the per protocol population. Secondary end points were not significantly different among the 2 groups (pneumonia, length of stay, and mortality), although the comparison of the Cormack and Lehane grade (Grades 3 and 4, 10% vs 5%; P <.001) and the longer intubation time (Intubation time >30 seconds, 47% vs 40%; P <.001) suggest an increased difficulty of tracheal intubation in the Sellick group., Conclusions and Relevance: This large randomized clinical trial performed in patients undergoing anesthesia with RSI failed to demonstrate the noninferiority of the sham procedure in preventing pulmonary aspiration. Further studies are required in pregnant women and outside the operating room., Trial Registration: ClinicalTrials.gov Identifier: NCT02080754.

Introduction: Dental injury is the most common incident associated with anaesthesia. Regarding recent recommendations on informed consent and changes in airway management practices, a large series of claims related to dental injury has not been recently described. The aim of this study was to analyse a recent database in order to describe the characteristics of dental injury in France., Methods: A database that prospectively collected claims reported to Le Sou Médical-MACSF between January 2003 and December 2010, was analysed. Five hundred and ninety-two cases were reported. The following characteristics were analysed: number and type of teeth injured, mechanism of injury, anaesthetic procedure, risk factors and dental outcome after injury., Results: Amongst the 1514 claims related to anaesthesia, 592 (39.2%) were classified as dental damage. Preoperative informed consent concerning possible perioperative dental injury was documented in only 34.8% of patients. Only one tooth was affected in 65.2% of patients, dental bridge injury in 12.8% of cases and damage to two or more teeth in 14% of patients. Incisors were involved in 50% of cases. Fracture was the most common type of injury (64.2%). Poor dentition was the most common risk factor (23.1%) followed by difficult intubation (15.4%). Both risks were combined in only 7.6% of cases. Tracheal intubation was the highest risk procedure (41.6%)., Conclusion: Dental injury remains the most common anaesthesia-related claim. Dental examination and documentation in patient medical files requires improvement and better informed consent on dental injury risk needs to be provided to patients., (Copyright © 2017. Published by Elsevier Masson SAS.)

The organization of health care establishments and perioperative care are essential for ensuring the quality of care and safety of patients undergoing outpatient surgery. In order to correctly inventory these organizations and practices, in 2013-2014, the French society of anaesthesia and intensive care organized an extensive practical survey in French ambulatory surgery units entitled the "OPERA" study (Organisation periopératoire de l'anesthésie en chirurgie ambulatoire). From among all of the ambulatory surgery centres listed by the Agences régionales de santé (Regional health agencies, France), 206 public and private centres were randomly selected. A structural (typology, organization) survey and a medical-practice survey (focusing on the management of postoperative pain, nausea and vomiting as well as the prevention of venous thromboembolism) were collected and managed by a prospective audit of practices occurring on two randomly selected days. The latter was further accompanied by an additional audit specifically focussing on ten representative procedures: (1) stomatology surgery (third molar removal); (2) knee arthroscopy; (3) surgery of the abdominal wall (including inguinal hernia); (4) perianal surgery; (5) varicose vein surgery; (6) digestive laparoscopy-cholecystectomy; (7) breast surgery (tumourectomy); (8) uterine surgery; (9) hallux valgus and (10) hand surgery (excluding carpal tunnel). Over the 2 days of observation, 7382 patients were included comprising 2174 patients who underwent one of the procedures from the above list. The analysis of these data will provide an overview of the organization of health establishments, the modalities thus supported and compliance with standards., (Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Background: Patient safety is improved by the use of labelled, ready-to-use, pre-filled syringes (PFS) when compared to conventional methods of syringe preparation (CMP) of the same product from an ampoule. However, the PFS presentation costs more than the CMP presentation., Objective: To estimate the budget impact for French hospitals of switching from atropine in ampoules to atropine PFS for anaesthesia care., Methods: A model was constructed to simulate the financial consequences of the use of atropine PFS in operating theatres, taking into account wastage and medication errors. The model tested different scenarios and a sensitivity analysis was performed., Results: In a reference scenario, the systematic use of atropine PFS rather than atropine CMP yielded a net one-year budget saving of €5,255,304. Medication errors outweighed other cost factors relating to the use of atropine CMP (€9,425,448). Avoidance of wastage in the case of atropine CMP (prepared and unused) was a major source of savings (€1,167,323). Significant savings were made by means of other scenarios examined. The sensitivity analysis suggests that the results obtained are robust and stable for a range of parameter estimates and assumptions., Study Limitations: The financial model was based on data obtained from the literature and expert opinions., Conclusion: The budget impact analysis shows that even though atropine PFS is more expensive than atropine CMP, its use would lead to significant cost savings. Savings would mainly be due to fewer medication errors and their associated consequences and the absence of wastage when atropine syringes are prepared in advance., (Copyright © 2016 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Volatile anaesthetic agents are used in the vast majority of general anaesthesias performed in France. We assessed the degree of understanding of French anaesthetists with regard to the general pharmacology of these products and their understanding of the factors that govern selection of the different agents available for use in adults. A validated 13-item questionnaire was sent electronically in 2012 using files from the Société française d'anesthésie et de réanimation (Sfar). It covered four categories: general characteristics of the respondent; practical aspects of anaesthesia with volatile agents; pharmacological properties and criteria for choosing a volatile agent; risk of intra-operative awareness. Among the 981 respondents, the anaesthetic technique used by 50% was that of an intravenous induction followed by maintenance with sevoflurane. The concepts relating to the practical use of these products are well known. A fresh gas flow of less than 2 L/min is used by 96% of the respondents. However, knowledge levels are often inadequate (rate of correct answers often<50%). This lack of knowledge pertains to current themes (climate pollution), those of debatable clinical significance, e.g. pre-conditioning, hypoxic vasoconstriction and those that concern scientific theory (medullary action). However, a lack of knowledge is also observed with regard to basic pharmacology (respiratory, vascular, neurological or pharmacokinetic effects). There is no significant difference in the mode of practice. The experience of the anaesthetist (measured by number of years post diploma) resulted in a number of differences in response to many aspects of the questionnaire but these were minor. These results suggest the need for an improvement both in the initial and continued training of anaesthetists with respect to volatile anaesthetic agents., (Copyright © 2015 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.)

Objective: The equipment and practices in obstetric analgesia, anaesthesia and intensive care, as well as their evolution between 2003 and 2010 in metropolitan France, were described., Population and Methods: Data were derived from two representative samples of births in 2003 and 2010, based on all births in France during one week. The sample included 534 maternity units and 14,903 births in 2010 and 618 maternity units and 14,737 births in 2003., Results: The caesarean operating room was adjacent or inside the labour ward in 66% of maternity units in 2010 vs 56% in 2003. An anaesthetist was appointed permanently to the labour ward in 38.9% of maternity units in 2010 vs 21.5% in 2003. Locoregional analgesia or anaesthesia rate increased significantly: 81.5% in 2010 compared to 74.9% in 2003. Almost all operative vaginal deliveries were performed under epidural anesthesia in 2010. Patient controlled epidural analgesia (PCEA) was available in 58% of the units in 2010 but only 34.2% of women had PCEA. Newborn's resuscitations were performed mainly by paediatricians in 2010, but 11.4% of children were resuscitated by an anaesthetist in level 1 maternity units., Conclusion: The conditions required to ensure anaesthetic care safety in maternity units has improved since 2003. Improvements in quality of care are still possible., (Copyright © 2012 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

The French law of December 4, 1994 has made the preanaesthetic consultation a mandatory part of the perioperative process. This consultation should be performed several days before surgery when the procedure is scheduled. This law has established that every patient undergoing surgery or an invasive procedure requiring anaesthesia should have a medical encounter with an anaesthetist to evaluate the risks associated with the procedure, inform the patient about the process and obtain his (her) agreement for the planned clinical pathway. During this encounter, the anaesthetist will also assess the perioperative risks related to an underlying disease (especially cardiac, respiratory and renal) while optimisation of a pre-existing condition is sometimes necessary before surgery. Patient's regular treatment might require some changes related to the effect of anaesthesia (antihypertensive drugs and risk of hypotension) or to the surgery (bleeding and anticoagulants/antiplatelet drugs). It is believed that the role of the general practitioner will increase significantly in the next years both in the preoperative period (drug adjustment, specific investigations) and in the postoperative period (especially after ambulatory surgery or in situations associated with a short hospital stay).

Background: Approximately 6600 cases of medical termination of pregnancy are performed in France annually, of which 78% are performed during the second or third trimester of pregnancy. There are few data and no recommendations regarding anesthesia and analgesia for these late terminations. The aims of this study were to determine the role of anesthesiologists and analgesia and anesthesia practices used for late terminations in France., Methods: An electronic mailing survey was sent to all obstetric anesthesia teams working in hospitals with a prenatal diagnosis center in France. The same survey was also sent to a sample of obstetric anesthesia teams working in hospitals near Paris without a prenatal diagnosis center., Results: The response rate was 96% (45/47) for those with and 85% (23/27) for those without a prenatal diagnosis centre. Anesthesiologists at units with prenatal diagnosis participate on a regular or frequent basis on multidisciplinary prenatal committees in 36% of responding centers and are involved in 69% of centers in case of maternal health problems. Epidural or more rarely combined spinal-epidural analgesia is performed in more than 90% of cases. The block is performed after fetocide in 22% of centers and after the start of labor in 38% of centers. Sedation or general anesthesia is used at delivery in every case or at patient request in 2% and 60% of centers, respectively. Minor differences were found when comparing practices of high-volume centers with prenatal diagnosis and small volume centers without., Conclusions: French anesthesiologists do not participate routinely in the decision and planning of all late terminations. Overall, very similar analgesic and anesthetic practices are observed in high- and low- volume centers, with epidural techniques being the most common., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Background: French regulations require that adverse events involving medical devices be reported to the national healthcare safety agency. The authors evaluated reports made in 2005-2006 for patients in anesthesiology and critical care., Methods: For each type of device, the authors recorded the severity and cause of the event and the manufacturer's response where relevant. The authors compared the results with those obtained previously from the reports (n = 1,004) sent in 1998 to the same database., Results: The authors identified 4,188 events, of which 91% were minor, 7% severe, and 2% fatal. The cause was available for 1,935 events (46%). Faulty manufacturing was the main cause of minor events. Inappropriate use was the cause in a significantly larger proportion of severe events than minor events (P < 0.001) and was usually considered preventable via improved knowledge or device verification before use. Compared to with that in 1998, the annual number of reported events doubled and the rate of severe events decreased slightly (12-10%, P = 0.03). The rate of events related to manufacturing problems remained stable (59-60%, P = nonsignificant), and the rate of events caused by human errors was 32-42% (P = 0.01). There were no changes in the mortality rate (2% in both studies)., Conclusions: The number of adverse events related to medical devices indicates a need for greater attention to these complex pieces of equipment that can suffer from faulty design and manufacturing and from inappropriate use. Improvements in clinician knowledge of medical devices, and to a lesser extent improvement in manufacturing practices, should improve safety.

Death certificates from the French national mortality database for the calendar year 1999 were reviewed to analyse cases in which airway complications had contributed to peri-operative death. Respiratory deaths (and comas) found in a previous national 1978-82 French survey (1:7960; 95% CI 1:12,700 to 1:5400) were compared with the death rate found in the present one: 1:48,200 (95% CI 1:140,000 to 1:27,500). In 1999, deaths associated with failure of the breathing circuit and equipment were no longer encountered and no death was found to be related to undetected hypoxia in the recovery unit. Deaths related to difficult intubation also occurred at a lower rate than in the previous report (1:46,000; 95% CI 1:386,000 to 1:13,000) in 1978-82 vs 1:176,000 (95% CI 1:714,000 to 1:46,000) in 1999, a fourfold reduction. In most cases, there were both inadequate practice and systems failure (inappropriate communication between staff, inadequate supervision, poor organisation). This large French survey shows that deaths associated with respiratory complications during anaesthesia have been strikingly reduced during this 15-year period.

Background: This study describes a nationwide survey that estimates the number and characteristics of anesthesia-related deaths for the year 1999., Methods: Death certificates from the French national mortality database were selected from the International Classification of Diseases, Ninth Revision codes using a variable sampling fraction. Medical certifiers were sent a questionnaire (response rate, 97%), and the anesthesiologist in charge was offered a peer review (acceptance rate, 97%). Files were reviewed to determine the mechanism of each perioperative death and its relation to anesthesia. Mortality rates were calculated using the number of anesthetic procedures estimated from a national 1996 survey and compared with a previous (1978-1982) nationwide study., Results: Among the 4,200 certificates analyzed, 256 led to a detailed evaluation. The death rates totally or partially related to anesthesia for 1999 were 0.69 in 100,000 (95% confidence interval, 0.22-1.2 in 100,000) and 4.7 in 100,000 (3.1-6.3 in 100,000), respectively. The death rate increased from 0.4 to 55 in 100,000 for American Society of Anesthesiologists physical status I and IV patients, respectively. Rates increased with increasing age. Although concerns regarding aspiration of gastric contents remain, intraoperative hypotension and anemia associated with postoperative ischemic complications were the associated factors most often encountered. Deviations from standard practice and organizational failure were often found to be associated with death., Conclusion: In comparison with data from a previous nationwide study (1978-1982), the anesthesia-related mortality rate in France seems to be reduced 10-fold in 1999. Much remains to be done to improve compliance of physicians to standard practice and to improve the anesthetic system process.

Background: Available literature on pregnant women with severe pulmonary hypertension (PH) relies mainly on anecdotal case reports and two series only., Methods: The authors reviewed the charts of all pregnant women with severe PH who were followed up at their institution during the past 10 yr, to assess the multidisciplinary treatment and outcome of these patients., Results: Fifteen pregnancies in 14 women with severe PH were managed during this period: There were 4 cases of idiopathic pulmonary arterial hypertension (PAH), 6 cases of congenital heart disease-associated PAH, 1 case of fenfluramine-associated PAH, 1 case of mixed connective tissue-associated PAH, 1 case of human immunodeficiency virus-associated PAH, and 2 cases of chronic thromboembolic PH. PH presented during pregnancy in 3 patients. Two patients died before delivery at 12 and 23 weeks' gestation. Four patients had vaginal deliveries with regional anesthesia: One died 3 months postpartum, one worsened, and two remained stable. Four had cesarean deliveries during general anesthesia: One died 3 weeks postpartum, one worsened, and two remained stable. Five had cesarean deliveries during low-dose combined spinal-epidural anesthesia: One died 1 week postpartum, and four remained stable. There were two fetal deaths: one related to therapeutic abortion at 21 weeks' gestation and one stillbirth at 36 weeks' gestation followed by the death of the mother 1 week later., Conclusions: Despite the most modern treatment efforts, the maternal mortality was 36%. Scheduled cesarean delivery during combined spinal-epidural anesthesia seemed to be an attractive approach, but there was no evidence of actual benefit. Therefore, pregnancy must still be discouraged in patients with severe PH.

Goal of the Study: To determine over a whole country what are the factors associated with an intraoperative homologous blood transfusion and with the use of autologous techniques (preoperative autologous blood donation: PABD; acute normovolemic hemodilution: ANVH; intraoperative red cell salvage: IRCS)., Study Design: National enquiry using a large representative sample (3 days of anaesthesia in France)., Methods: Univariate followed by multivariate analyses of data gathered in 1996 during the survey leaded by the French society of anaesthesia and intensive care (Sfar) and corresponding to 884 scheduled hip and knee prosthesis surgical procedures., Results: Factors associated with a decreased use of PABD programme were: 1--old age and high ASA physical status; 2--procedures of short duration. By contrast, an increased use of PABD was associated with anaesthetics in which a closed circuit had been used. Except for a significant association with increasing age and with absence of PABD used, no additional factor was found to be linked with ANVH. No factor among those studied was found related to the use of IRCS. Homologous blood transfusion was more frequently used in ASA > or = 3 patients, in long duration surgeries while its use was decreased in patients with PABD (odds ratio--for reduction by PABD: 4.4 [95% confidence interval: 2.2-8.8]). Homologous blood transfusion was not related to the use of ANVH or IRCS., Conclusion: These data obtained from a large national survey confirm previously published studies and meta-analyses and are in agreement with current recommendations. An unexpected relation between PABD and closed circuit anaesthesia has been found.

Objective: The aim of this study was to evaluate the satisfaction of adult surgical patients before and after an information booklet concerning anaesthetic techniques and complications, and postoperative management has been proposed during preanaesthetic visits., Study Design: Survey., Method: Three surveys have been performed using an anonymous questionnaire of 25 items with graduated answers (very good, good, bad, very bad, no opinion) concerning patient satisfaction on structure, physician behavior, information and well being. As the results of the first two surveys were not significantly different, an information booklet was proposed to patients during preanaesthetic visits, then a third survey ("After") was realized. The results of this survey were compared to the combined results of the first two surveys ("Before")., Results: In the "before" survey, 60 to 76% of the patients were satisfied (very good and good) of the information delivered during preanaesthetic visits. The proportion of patients satisfied of the information concerning anaesthetic techniques, transfusion and recovery were significantly higher in the "after" survey (P < 0.05)., Conclusion: An information booklet on anaesthesia increases patient satisfaction on information provided during preanaesthetic visits.

Abstract: Background: Medication errors are a significant cause of severe healthcare-associated complications. In December 2006, the French Health Products Agency (Afssaps) has issued a protocol to harmonise labeling of injectable drugs vials. In 2007, a first change was launched for four drugs and was followed in 2008–2009 by a second wave concerning 42 active drugs. Methods: The present study describes how healthcare professionals have perceived this change and their overall appreciation of the drug harmonisation programme. A survey using an electronic questionnaire was distributed to medical and non-medical professionals in anaesthesia and intensive care and pharmacists in a representative sample of 200 French hospitals. Results: The harmonisation procedure was felt as being overall satisfactory by 53% of professionals who had responded but it was recognised that the new procedure is associated with improved readability and understanding of drug dosage. The use of colour coding was also well accepted by the personnel of clinical units. Respondents expressed significant criticisms regarding both the communication plan and the way the plan was implemented locally in hospitals. Old and new labeling coexisted in 66% of responding hospitals and many respondents described being aware of errors or near-misses that were considered related to the transition. For many important topics, pharmacists had views that were significantly different from clinicians. Conclusion: This national survey describing the perception of healthcare professionals regarding the new harmonisation procedure for injectable drugs highlighted some progress but also a number of deficiencies, notably regarding communication and implementation of the change in clinical units. This survey will be used by the French Health Products Agency to improve future steps of the long-lasting campaign against medication errors. [Copyright &y& Elsevier]

Purpose: To investigate if early epidural analgesia can influence fetal head engagement into the pelvis and if it can increase the rate of transverse and asynclitic position during labour. Materials and Methods: 195 women with combined spinal-epidural analgesia (CSE) or without neuraxial analgesia were studied. CSE was performed using a mixture of ropivacaine 0.02% with 0.3 µg/ml of sufentanil administered in the spinal space. Maintenance of analgesia was managed with intermittent epidural administration of 10-15 ml of ropivacaine (0.07%-0.10%) mixed with 0.5 µg/ml of sufentanil, based on the stage of labour and the degree of pain. 2D transabdominal ultrasound (US) was used. Serial transabdominal US examinations were performed at 45-90 min intervals to detect transverse and asynclitic positions, using the following signs: squint sign, sunset thalamus and cerebellum signs that best details the fetal head station. After delivery, the complete set of clinical and US data obtained by each examination were recorded and compared in women with and without labour analgesia. Data were examined by independent reviewers. Results: There was no difference in obstetric outcome between women in whom CSE had been used and those who did not request analgesia during labour (p>0.05). Conclusions: Epidural analgesia initiated early during labour and using low doses does not increase the rate of dystocic labors. Transverse fetal head positioning with anterior or posterior asynclitism does not seem to be promoted by drug or technique-related mechanisms, but rather should be the consequence of cephalopelvic disproportion. [ABSTRACT FROM AUTHOR]

Cytokines are secreted locally in response to surgery and may be released into the systemic circulation. Reactive oxygen species (ROS) production is involved in various inflammatory conditions. The aims of the study were to examine the magnitude of surgical stress on the modulation of immune response and ROS production. Patients undergoing low- and intermediate-risk surgery ( n=32) were enrolled. Blood samples for tumor necrosis factor (TNF)α, interleukin (IL)1β and IL10 assays were obtained before anesthesia, immediately after extubation, at 24 and 72 h after surgery. Measurement in whole-blood cultures of ex vivo lipopolysaccharide (LPS) and Staphylococcus aureus Cowan (SAC)-stimulated production of cytokines was carried out. The pro-oxidant potency of the whole serum was assessed in human umbilical vein endothelial cells using a fluorescent probe after stimulation by the plasma collected at the same time intervals. TNFα, IL1β and IL10 did not increase significantly after surgery in either group. Whole-blood cultures response to LPS and SAC stimulation decreased for IL1β at the end of surgery in the two groups and returned to normal within 24 h after surgery. LPS- and SAC-induced IL10 production increased significantly at 24 h in the low-risk surgery group. ROS production was greater after more stressful surgery and was correlated to morphine consumption. Cytokine release in the systemic circulation was not well correlated to the magnitude of surgical stress, whereas transient immune hyporesponsiveness was seen after moderately stressful surgery. ROS production might be a more accurate indicator of the severity of surgical trauma. [ABSTRACT FROM AUTHOR]

Abstract: Aspiration of gastric contents is a major complication in relation with the practice of anaesthesia. The present article is aimed at describing detailed data related to aspiration which were obtained during the French national survey on anaesthesia-related mortality conducted by both Sfar and CépiDC–Inserm. Information regarding methods of the survey and the main results has been previously published. In brief, the first part of the survey described the number and characteristics of anaesthetic procedures performed in 1996 (denominator). The second survey analysed deaths related to anaesthesia which were identified from death certificates of the calendar year 1999. Because of the numerical importance of aspiration among the causes of deaths, a secondary analysis was undertaken to assess into details factors leading to the occurrence of this complication. Eighty-three cases of death were found related to aspiration, i.e. one-fifth of deaths related completely or partially to anaesthesia, implying a death rate of one for 221,368 general anaesthetic procedures or 4.5×10−6 (95% IC: 0.8×10−6–14×10−6). Patients involved were all in a severe clinical condition (ASA≥3: 92%), very old and often scheduled for urgent abdominal surgery. Two cases of death occurred during colonoscopy but none in obstetric patients. Aspiration almost always occurred during induction of anaesthesia. Analysis of practice patterns disclosed significant deviations from recommendations. French anaesthetists should voluntarily move through a personal and active process toward an improvement of their practice to reduce the incidence of aspiration. [Copyright &y& Elsevier]

Background: Hypothermia has been proposed as a therapeutic possibility in brain trauma, cardiac arrest and hemorrhagic shock. Experimental studies have shown that hypothermia may act by modulating the inflammatory response during endotoxemia. This study was carried out to test whether hypothermia could protect rats from endotoxemic insult. Methods: After general anesthesia and oro-tracheal intubation, Sprague–Dawley rats were randomly assigned to either a hypothermic group or normothermic group. In each group, rats received intraperitoneal lipopolysaccharide (LPS) (10 or 20 mg/kg). Blood samples were taken prior to and 2 h after LPS injection to measure blood gases, liver enzymes, muscular enzymes, tumor necrosis factor-α (TNF-α) and interleukin-10 (IL-10) plasma levels. After 2 h of hypothermia, the rats were extubated and brought back to their cages. The mortality rate was observed for 7 days following endotoxemia. In a second set of experiments, hypothermia was induced 1 h after endotoxemia (10 mg/kg of intraperitoneal LPS) and the mortality rate was observed for the following 7 days. Results: The survival rate was significantly increased in the hypothermic group relative to the normothermic group, regardless of LPS dose. This increased survival rate was also observed when hypothermia was induced 1 h after endotoxemia. In the hypothermic group, IL-10 and the ΔIL-10/ΔTNF-α ratio were significantly increased relative to those in the normothermic group. Conclusion: Induced mild hypothermia reduces mortality during endotoxemia in rats. The modulation of the inflammatory response, with an increase in anti-inflammatory cytokines, may be involved in this protective effect. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The purpose of this review article is to update the anaesthetic management of adult patients with obstructive sleep apnoea syndrome (OSAS). Data sources: All references obtained from the medical database Medline® related to OSAS and anaesthesia from 1963 until May 2006 were reviewed. References included original articles, observations, clinical cases, and reviews published in English or in French. Data Synthesis: The anaesthetic literature related to OSAS and anaesthesia is poor. Understanding anatomy and pathophysiology is important for an optimal anaesthetic management. Since the diagnosis is unknown in almost 80–90% of these patients, many undergo general or regional anaesthesia every day without recognition of the main dangers associated with the condition. Recognition of these patients, especially in the preanaesthetic assessment, is an essential step to prevent perioperative complications. Patients with OSAS are very sensitive to sedatives, hypnotics and opioids. The use of these drugs must be controlled and monitored. Anticipation of difficult intubation avoids complications during induction of general anaesthesia and the use of nasal CPAP decreases the incidence of respiratory complications in the perioperative period. Conclusion: Further research is needed in this field of anesthesia. Intraoperative difficulties in the control of airway and postoperative cardiac and respiratory complications may happen. The use of nasal CPAP in the perioperative period makes the anaesthetic management easier and safer. [Copyright &y& Elsevier]

Objective. – To study the reciprocal interferences between pregnancy and myasthenia gravis (MG) and to describe obstetric and anaesthetic management during labour and the post-partum period.Study design. – Retrospective, single centre study.Methods. – The files of 10 patients with MG, who delivered between October 1994 and May 2002, were examined.Results. – No stillbirth occurred and all pregnancies were brought to term. All patients were maintained on their long-term anticholinesterase medications during pregnancy. Seven exacerbations were detected and controlled, five by increasing the anticholinesterase treatment, one by using plasmapheresis and one by using intravenous immunoglobulins. No patient required admission to the intensive care unit during pregnancy. All patients had a pre-anaesthetic visit at/near 33 weeks of gestation. Delivery was induced for six patients. Regional analgesia was performed early in labour (epidural, n = 7; combined spinal–epidural = 2) using low concentrations of local anaesthetic and no complication was detected. Three patients required a caesarean section for an obstetrical indication. Seven patients delivered vaginally using instrumental extraction (n = 5). During the post-partum period, four patients were monitored in the intensive care unit during 48 h and close neurological follow-up disclosed no exacerbation during the first 6 post-partum weeks.Conclusions. – MG has no significant effect on the course of pregnancy and delivery, but MG exacerbation can occur, especially in the first trimester. Regional analgesia is medically indicated and must be performed early in labour, using low concentration of local anaesthetic to lessen the risk of motor block. [Copyright &y& Elsevier]

Introduction of new legal texts in 1994–1995 has certainly contributed to the improved safety of anaesthesia practice in France. More recently also legal texts have been published in this country to improve the practice of obstetrics. These two series of texts have had a significant impact on obstetric anaesthesia, improving care directly related to anaesthesia practice (such as visit with an anaesthetist during pregnancy for every patient) but also care of patients with maternal disease through the implementation of regionalisation and of perinatal networks. Significant problems however need to be solved if one wants that improvement in quality continues. Precise evaluation of practice patterns and of outcomes will become possible only when well-defined indicators will have been found and accepted. Also, regionalisation of obstetric services has led to a profound change in workload with an increase in both anaesthesic procedures and stress related to urgency situations in tertiary level perinatal units. Regionalisation has been introduced to reduce perinatal mortality and morbidity. However, maternal complications of obstetric or of pre-existing diseases may require specific competence that may not be available in perinatal centres specifically organized to improve neanatal outcome. High-level perinatal centres should thus be able to care for both the mother and the neonate. Alternatively, when not feasible, specific rules or protocols should be made available to optimize the transfer while taking into account the severity of maternal disease. All these continuing improvements will however be possible only if shortage of specialists of perinatal care stops. [Copyright &y& Elsevier]

Previous reports have demonstrated a gastric emptying effect of erythromycin due to a motilin-like mechanism. We studied 50 patients, scheduled for daycase laparoscopy, randomly assigned to one of two groups: Group P patients received 30 min before induction of anaesthesia, in a double-blind manner an infusion of 250 ml dextrose 5% while patients in Group E (n = 25) received 500 mg of erythromycin diluted in 250 ml dextrose 5%. An orogastric tube was inserted to measure both gastric pH using a pHmeter and residual gastric volume (RGV) using the phenol red dilutional technique. Six patients were excluded for surgical reasons. More patients in Group P (6/22) than in Group E (0/22) had RGV > 25 ml and more patients in Group P (17/22) presented with a gastric pH < 2.5 than in Group E (5/22), P < 0.05. Since coma and respiratory depression have been reported recently after midazolam and alfentanil administration in patients having received erythromycin, recovery conditions were assessed and were found to be comparable between groups. In conclusion, the administration of iv erythromycin before outpatient laparoscopy decreased residual gastric volume and increased gastric pH without affecting recovery from general anaesthesia. [ABSTRACT FROM AUTHOR]

Abstract: A 29-year-old patient was scheduled for bilateral halllux valgus surgery and a lateral sciatic popliteal nerve block was performed on each side using ropivacaine and lidocaine using nerve stimulation. Although the sensory and motor block had usual duration on the left side, the block lasted more than 48hours on the right side with both sensory and motor impairment. An MRI performed on day 2 on the blocked side showed extra- and intraneural fluid accumulation with cephalad and distal spread. Sensory and motor function progressively recovered within the next day and was complete on the fourth day. We postulate that this case of extremely long duration of a peripheral nerve block can be ascribed to subepineural trapping of the local anaesthetic. Part of the variability in the duration of the sensory and motor block after peripheral nerve blocks might be explained by the variable amount of drug injected intraneurally. [ABSTRACT FROM AUTHOR]

A recent French survey showed that the techniques of anesthesia have changed dramatically since the beginning of the 1980's. This is particularly true for regional anesthesia (RA) the use of which has increased from 4% of the 3,600,000 anesthetic procedures in 1980, to 23% of the 7,937,000 procedures in 1996. For several specific operations, the decision to undertake general anesthesia (GA) instead of RA is easy or has proven advantages. However, in many circumstances this decision is questionable because neither technique has definite and proven advantages.

A letter to the editor is presented in response to the article "The Effect of Two Cognitive Aid Designs on Team Functioning During Intra-Operative Anaphylaxis Emergencies: A Multi-Centre Simulation Study" by S. D. Marshall and colleagues in the 2016 issue.