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Traumatic injury of the common bile duct is extremely rare, especially when it is isolated. It usually occurs after laparoscopic biliary tract surgery. This lesion is often associated with one or multiple lesions of the neighborhood organs. We report a case of isolated injury of the common bile duct following abdominal trauma in a 5-year old child treated in our Department at the Mother-Child Hospital in Nouakchott. Radiological exploration didn't provide a conclusive diagnosis. Exploratory laparoscopy was performed because surgery had revealed diffuse biliary peritonitis secondary to a lesion at the bottom of the common bile duct. Emergency treatment was based on lavage with external biliary drainage followed, after a month, by bilio-digestive anastomosis. Life-threatening complication of common bile duct injuries is biliary peritonitis. In the literature, early postoperative morbidity is 20-30% while mortality rate is 0-2%. Isolated traumatic injury of the common bile duct in children is a lesion whose clinical course and therapy should be known in order to decrease morbi-mortality. Treatment is based on a multidisciplinary approach involving the pediatric surgeon, the radiologist and the resuscitating anaesthesiologist. [ABSTRACT FROM AUTHOR]

Background This survey aimed to describe the current use of laryngeal mask (LM) and to define the difference of use according to a group defined like experts. Methods A self-questionnaire available on Internet was sent by e-mail to French anesthesiologists. Results were compared by a Chi2 test between anesthesiologists according to their expertise defined by a >750 LM use. Results Nine hundred and fifty-three anesthesiologists answered to the survey. Only 19 reported never using LM and 37% of responders were defined as expert. More than half of the MAR used the ideal weight to set the size of the MLA to use. Pressure leak was sought by less than one-third of the MAR. In case of leakage, a mobilization of the ML or the patient's head was performed first. In second intention, nearly a quarter of MAR changed technique for the benefit of oral intubation. Only 50% of responders used LM as a rescue technique in case of difficult intubation and ventilation. Experts had less insertion failure and laryngospasm. Complications and medico-legal suites are few. Conclusions Variability of practice may be explained by low-grade recommendations in the literature. LM insertion in case of difficult intubation/ventilation to provide adequate oxygenation and should be formally reminded to clinicians. [ABSTRACT FROM AUTHOR]

Objective. - To determine current clinical neuromuscular use in Morocco anesthetic practice. Study design. - Clinical practice survey. Methods. - Anesthesiologists were invited to answer anonymously to question about neuromuscular blocking agents (NMBA): pharmacology, monitoring and antagonism drug use. Corrected yates test was used to compare qualitative parameters and variance analysis for quantitative parameters. P < 0.05 was considered as significant. Results. - We had 171 answers, 54% were paramedics (n = 93) and 46% (n = 78) were physicians (20% global effective in Morocco). Fifty-five percent were seniors. Vecuronium was the most NMBA used in Morocco for 51% of the anesthesiologists. Mean action time of NMBA was underestimate in more than 60% of the staff questioned specially for seniors (24.6%) than juniors (19.2%). Residual neuromuscular blockade was evaluated only by clinical and spirometric parameters in 72%. TOF monitor was used in 18% more in military hospitals (36%) and insurance clinics (40%) than private hospitals (12.5%). Administration of reversal drugs was systematic in 5.8% of anesthesiologists, frequent for 36.3% and rare for 55%. Conclusions. - This study show an underestimation of residual neuromuscular blockade, poor neuromuscular monitor use and lack of knowledge of NMBA specially for senior anesthesiologists and in private hospitals. We should elaborate Moroccan guideline for NMBA use and provide formal training programs for our anesthetic staff. [ABSTRACT FROM AUTHOR]

Résumé: Objectif: Décrire la demande en anesthésistes-réanimateurs remplaçants (ARR), les conditions d’accueil et de travail de ces professionnels dans les centres hospitaliers généraux de la région Rhône-Alpes (CHGRA). Investigation et mesures: 1) Enquête téléphonique auprès de toutes les directions des CHGRA ; 2) proposition de remplacement pour une période de cinq jours sans participation à la permanence des soins (PDS) ; 3) évaluation de l’accueil administratif et médical ; des conditions de travail, de critères subrogés évaluant la qualité d’organisation et des soins ; 4) mesure de la taille et de l’activité des établissements sur le logiciel ű Platines Ƈ (ministère de la Santé). Résultats: Parmi les 32 directions des CHGRA interrogées, 28 ont déclaré être en recherche d’ARR mais seulement 11 (34 %) ont accepté une période d’adaptation avant la participation à la PDS (CHG1), pendant que 17 (53 %) refusaient cette clause (CHG2) et quatre ne recherchaient pas d’ARR (CHG3). L’accueil de l’ARR, le fonctionnement et les normes professionnelles étaient très diversement effectués dans les 11 CHG1 dans lesquels un remplacement a été effectué. Aucune direction hospitalière n’a effectué d’entretien d’évaluation. Il n’y avait pas de différences de taille ou d’activité entre les trois groupes de CHG. Conclusion: Le besoin d’ARR est très fréquent dans les CHGRA et cette pratique n’est pas encadrée. Aucune stratégie d’intégration de l’ARR et de recrutement n’a été identifiée. Cela questionne sur ce que l’institution attend de l’anesthésie-réanimation dans les hôpitaux publics. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Enhanced recovery is a concept currently recognised and adopted in a number of surgical specialties. In obstetrics however, this concept remains surprisingly underdeveloped. The purpose of this survey was to study the practice of obstetric anaesthetists in France as regards the recovery of women undergoing uncomplicated, elective caesarean section. Material and method: An online 39-point questionnaire was displayed for 2months on the Caro (Club d’anesthesie réanimation en obstétrique) website. The questionnaire related to uncomplicated, elective Caesarean sections and aimed to define the following: preoperative information given regarding the recovery period, intraoperative care – both anaesthetic and surgical, postoperative analgesia, measures taken to prevent post-partum haemorrhage, reintroduction of fluids and diet, return to mobility, local practices designed to promote bonding between mother and baby. Results: The overall response rate for our survey was 45%. Forty-nine percent of practitioners report that patients are provided with specific information on the recovery period preoperatively. Sixty percent of those surveyed state the absence of any specific recovery protocol for this patient population in their hospital. Eighty-one percent of respondents state that, in the majority of cases, patients are admitted on the eve of surgery and remain hospitalised for more than 72hours (89%). Ninety-nine percent of practitioners employ a regional technique to deliver anaesthesia for elective section and 44% rely on intrathecal morphine for postoperative analgesia. The concept of ‘Patient Controlled Oral Analgesia’ (PCOA), although widely recognised, is used by only 17% of practitioners. Forty-one percent of practitioners report the reintroduction of fluids as soon as patients return to the ward following surgery and at the same time as the urinary catheter is removed (51%). Diet is commenced 4 to 6hours following surgery amongst 40% of those surveyed. Fifty-one percent of practitioners report removal of the intravenous catheter 24hours postoperatively. Finally, 49% of practitioners feel patients are independently functioning and mobile within 24hours of surgery. Conclusion: This survey of national practice shows that the concept of ‘enhanced recovery’ following elective caesarean section can be again developed. Standardisation of practice with the design of local protocols relating to postoperative analgesia, timing of removal of the intravenous access and urinary catheter, time to first mobilisation and to commencement of diet would appear to be warranted. Surely this surgery, more than any other, merits an expeditious and effective return to normal and independent function, allowing mother to better look after baby. [Copyright &y& Elsevier]

Surgery is the main treatment for gastric adenocarcinoma. Surgical quality criteria depend on one hand on the resection quality and compliance of carcinologic rules, and on the other hand on measures allowing perioperative care optimization. Immunological nutrition is part of preoperative optimization. Anaesthesiologists have to maintain volemia in the limits allowing the best oxygen blood transport. Artificial ventilation has to limit asmuch as possible the pulmonary barotraumatism. Surgeons must know the rare indications of metastases resection. For becoming a recommendation, laparoscopic gastrectomy would require a large multicentric clinical trial. [ABSTRACT FROM AUTHOR]

Abstract: A recent survey among French anesthesiologists revealed that monitoring of curarization is used in approximately in 50% of cases after a unique dose of curare and in 75% of cases after repeated doses of curare. In this survey, a majority of clinicians used a quantitative monitor based on acceleromyography, i.e. that the majority of clinicians used a device from the TOF-watch® product line. Results obtained by these monitors depends on the model used, TOF-Watch®, TOF-Watch S® or TOF-Watch SX®, as well as if it is used for a single point measurement at the end of the operation or continuously throughout the operation, with or without calibration, and if a calibration is used, should we used Cal 1 or Cal 2? Technical specifications and their impact on results will be developed in this technical note. This will help clinicians to better interpret results obtained by TOF-watch® monitors in order to improve clinical decisions based on monitoring of neuromuscular transmission. [Copyright &y& Elsevier]

Abstract: Introduction: Medication errors are a major public health problem because of their morbidity and financial costs. In anesthesia, few articles publications, mostly retrospective, have assessed its incidence and outcomes. By our prospective study, we intend to identify and describe the drug errors in anesthesia in four university hospitals in Morocco. Material and methods: After approval of our ethics committee, a prospective study was conducted in nine hospitals affiliated to four university hospitals (Rabat, Casablanca, Fes and Marrakech) from October 2009 to June 2010. Data collection was carried out by an anesthesiologist at each hospital who was designated by the investigator. Informations were based on practitioner''s statements. Medication errors were divided into distinct categories: substitution errors, omission errors, errors of the way of administration, dosage and dilution errors. The consequences were classified into four levels according to their severity. Results: During the study period, 9199 anesthetic procedures were reported (mean response of 36%). General anesthesia was performed in 75% of patients. Sixteen cases of drug errors were reported (an incidence of 1/575 with 1/405 in a pediatric setting). The drugs involved were dominated by hypnotics (six cases/16) and morphine (four cases/16). Medication errors were mainly due to labeling mistakes (seven cases/16) and to attention deficit due to fatigue and stress (seven other cases) leading to substitution error in most of cases (10 cases/16. Errors were mainly made by the less experienced practitioners (14 cases/16). They occurred during the induction phase (seven cases/16) as well as during the interview process (nine cases/16), and also during emergent surgeries (seven errors/16) as well as during elective ones (nine errors/16). No errors caused death. Pulmonary edema (recognized as a grade III severity incident) was secondary to inappropriate administration of adrenaline. Conclusion: Our study helped us to set recommendations, which are approved by the Moroccan pharmacovigilance center, and in accordance with the international committees to prevent the occurrence of medication errors in our daily anesthetic practice. [Copyright &y& Elsevier]

Abstract: Objective: Femoral Nerve Block (FNB) has been proposed for femoral fracture analgesia in a prehospital setting. Methods: Descriptive case-series survey. All suspected femoral fractures that were managed by our extrahospital service and had a femoral block were prospectively included. The physician was free to choose any block technique (paravascular femoral block [BFPV], nerve stimulation femoral block [BFNS], or fascia iliaca block [BFI]), as well as local anesthetic mixture and volume. Pain was assessed using a simplified verbal scale (0–4) before (T0), 10minutes after block (T1), and at hospital arrival (T2). Demographic values, actual trauma diagnosis, the technique used, the local anesthetic mixture and volume, incidents and complications were recorded. Results: One hundred and seven blocks were included. Eighty-six percent of the blocks were performed by an anesthesiologist, although they represent 50% of the prehospital physician staff. Pain on the simplified verbal scale (EVS) decreased from T0 to both T1 and T2 for the whole population and also in each technique subgroup (eight BFPV, 36 BFNS, and 63 BFI). Two BFI blocks required a re-injection to be successful. Ten blocks failed (eight BFI, and two BFNS). Among those 10 failed blocks, two were first wrongly quoted as successful and two successful BFNS blocks appeared inadequate with regard to the trauma location outside the femoral dermatoma. No complication was observed. Conclusion: Prehospital FNB appeared to be efficacious in routine practice. Teaching FNB to non-anesthesiologist physicians is challenging. [Copyright &y& Elsevier]

Abstract: Objective: To assess knowledge amongst anaesthetists as regards to fire involving surgical patients in Lorraine. Study design: A cross-sectional study was conducted using a postal questionnaire. Method: A 22-item postal questionnaire was therefore sent to all anaesthetists working in Lorraine between January and March, 2011. Results: One hundred and twenty-eight questionnaires were returned (response rate: 36%). Sixty-two percent of the respondents had never participated in fire safety training. Fifty percent could not recollect the location of the fire extinguisher in their surgical unit. Sixty-three percent ignored the existence of a memo written by the Afssaps summarizing how to use safely alcohol-based skin preparations in the presence of an electrosurgical unit. Sixty-five percent gave at least one incorrect response in grading the various modes of oxygen supply regarding the risk of fire. Only 48% were able to identify the surgeries which posed the greatest fire risk. In such cases, 40% of respondents were not aware that a FiO2 should be maintained below 30%, 43% that the use of nitrous oxide was forbidden and 32% that it was necessary to respect a drying time after the application of an alcohol-based solution. Concerning the management of a fire, most of the answers were correct. Finally, 97% of the respondents wished to be better informed on this particular topic. Conclusion: Our survey underlines a lack of knowledge amongst anaesthetists towards the risk of patient associated fire in theatre. [Copyright &y& Elsevier]

Abstract: Antiphospholipid syndrome (APS) is associated with a risk of obstetrical complications, affecting both the mother and the fetus. Obstetrical APS is defined by a history of three consecutive spontaneous miscarriages before 10 weeks of gestation (WG), an intra-uterine fetal death after 10 WG, or a premature birth before 34 WG because of severe pre-eclampsia, eclampsia or placental adverse outcomes (intrauterine growth retardation, oligohydramnios). Pregnancy in women with a diagnosis of obstetric APS is at increased risk for placental abruption, HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome and thrombosis that may be part of a catastrophic antiphospholipid syndrome (CAPS). A previous thrombosis and the presence of a lupus anticoagulant are risk factors for pregnancy failure. A multidisciplinary approach, associating the internist, the anesthesiologist and the obstetrician, is recommended for these high-risk pregnancies. Preconception counseling is proposed to identify pregnancy contraindications, and to define and adapt the treatment prior and during the upcoming pregnancy. Heparin and low-dose aspirin are the main treatments. The choice between therapeutic or prophylactic doses of heparin will depend on the patient''s medical history. The anticoagulant therapeutic window for delivery should be as narrow as possible and adapted to maternal thrombotic risk. There is a persistent maternal risk in the postpartum period (thrombosis, HELLP syndrome, CAPS) justifying an antithrombotic coverage during this period. We suggest a monthly clinical and biological monitoring which can be more frequent towards the end of pregnancy. The persistence of notches at the Doppler-ultrasound evaluation seems to be the best predictor for a higher risk of placental vascular complications. Treatment optimization and multidisciplinary antenatal care improve the prognosis of pregnancies in women with obstetric APS, leading to a favorable outcome most of the time. [Copyright &y& Elsevier]

Abstract: Introduction: Dental injuries are among the most common complications of general anesthesia. Yet few studies have assessed the costs and factors that involve the responsibility of the anesthetist. Study design: A retrospective study was conducted at the university hospital of Reims on 46 cases of dental injuries directly related to anaesthesia. Results: Ten patients made a claim for compensation. Two of them have received compensation following a medical expertise, which revealed for the first patient a possible alternative to general anaesthesia, and the second, hardware failure of intubation. The Administrative Court was entered once in 9 years. The global insurance-cost amounts to 4476 euros for all patients. The review of all cases of anaesthesia shows clearly that the dental claims are associated with a significant under clinical evaluation of dental status and criteria for difficult intubation during the anaesthesia. The information to the patient on this risk is not obvious from reading the anaesthesia records. No mouth guard was used. Conclusion: This work proves that the statements of caution are the most common and a minority of dental trauma lead to a claim. Claims are due to the high cost of dental care repair. The proportion of patients receiving benefits is extremely low. Medical expertise is an essential part of the evaluation of medical responsibilities. No compensation was paid without expertise. The lack of physical examination and information are contrary to our professional obligations and may involve our responsibility. The lack of patient information is not generated for compensation to the extent that the consequences of failure are easily dental weighed against the benefits of the entire medical-surgical procedure that the patient has agreed. [Copyright &y& Elsevier]

Abstract: We report the case of a patient who presented hypertension paroxysmal with acute pulmonary oedema followed by cardiocirculatory arrest during gynaecological surgery for resection of latero-aortic lymph nodes suspected to be cervical cancer metastases. This intervention, originally oncologic, has discovered ectopic phaeochromocytoma a posteriori. The management of perioperative serious adverse events revealing the undiagnosed phaeochromocytoma is discussed. [Copyright &y& Elsevier]

Abstract: Oesophago-gastro-duodenoscopy for diagnostic is daily performed in adults and in children during sedation with propofol. This is administrated in France by anaesthesiologists. Pulmonary or cardiovascular complications are rare. We report a case of massive inhalation during an EGD with a teenager. The assessment has revealed an oesophageal achalasia, a condition rare in children and atypical development. This case highlights the importance of systematic screening for risk of a full stomach during the anaesthesia consultation, and the difficulty in evaluation in case of medical migrant patient. [Copyright &y& Elsevier]

Abstract: Objectives: To report any item documenting the peroperative muscle relaxant effects management in anaesthesia files issued from visceral surgery processes. Type of study: Prospective, observational and multicenter. Patients and methods: A single operator analysed 1453 files proposed by nine anaesthetists’ teams. The items selected concerned three periods: induction/tracheal intubation, paralysis maintenance, tracheal extubation. Reporting of 40 categories of items was studied. Results: Items related to laryngoscopy and intubation conditions were observed in 43% (0–95) [general average (intercentres min–max)] and in 11% (0–97) of the files, respectively. At least one level of paralysis was reported in 23% (0–96) of the files. For the paralysis maintenance, documentation of an effect appeared in 53% (4–96) of the documents. Neuromuscular assessments preceding the tracheal extubation were retrieved in 43% (12–89) of the notes. Adductor pollicis was concerned for 30% (1–89) of these observations. Detection of level of spontaneous paralysis offset, satisfying to the local standard, appeared in 14% (3–19) of the documents. Pharmacological reversal was noted for 25% (4–67) of the patients; the assessment of the effects so produced was reported in 8% (0–58). Conclusion: In the studied collection, the traceability of the peranaesthetic curarization management appears variable on both qualitative and quantitative levels. The emergence of a dedicated guideline – defining the criteria for producing a good documentation of the muscle relaxant use – becomes necessary to secure these practices for all physicians using muscle relaxants. [Copyright &y& Elsevier]

Abstract: Objective: Burnout is one of the main chronic health problems with negative consequences on health care givers but also on quality of care. The main goal of Physician Health Survey was to study the frequency of burnout among salaried physicians and pharmacists and to compare anesthesiologists and intensivists (AI) with other practitioners (OP). The secondary end points were to analyze risk factors of burnout in each group. Material and methods: An anonymous, self-administered questionnaire was diffused via a specific website. Burnout was measured using the Copenhagen Burnout Inventory (CBI). Several different factors were examined: work/family conflict, salary satisfaction, quality of teamwork, interpersonal relationships, workplace influence, workload and perceived health. The role of each factor was calculated by multivariate logistic regression and comparisons were made between AI and OP. Results: Among the 3196 responses, CBI revealed an elevated score of burnout in 38.4% in AI and in 42.4% in OP. In each group, a great gap was displayed between the CBI results and the self-assessment of burnout (15%). Among AI, risk factors of burnout were high quantitative demand (ORadj=3.40; CI95 1,34–8,63), Work/family conflict (ORadj=; 3.12 CI95 1.60–6.08), low quality of teamwork (ORadj=1.99; CI951.14–3.47) and tense Relation within team (ORadj=1.92; CI95 1.25–2.95). All these factors are observed also among OP. Female gender, young age and dissatisfaction with pay have significant influence but different in the two groups. Claims of recurrent harassment by superiors is a risk factor for burnout only for the AP (adj.OR=1.83; CI95 1.04–3.22). Discussion: Burnout affected near one about two salaried physicians and pharmacists in France. AI were not more concerned by burnout than OP but all of whom have difficulty identifying their own levels of psychological stress and burnout. Decreasing the level of different risk factors i.e. by improving the quality of teamwork should lead to reduce burnout frequency. [Copyright &y& Elsevier]

Abstract: Objective: To improve the quality of proton pump inhibitors (PPI) prescription in an orthopaedic department. Study design: Prospective professional practice evaluation study. Patients and methods: A specific protocol concerning the best practice for using PPI in the perioperative period was established by anaesthesiologists and validated by all prescribers, according to recent recommendations published by French Afssaps. PPI prescription pertinence, mainly using the oral route, was based upon the presence of clearly identified risk factors. PPI mensual consumption and severe gastric complications were analyzed and compared with those obtained from the previous year. Ten months after the beginning of the protocol, the pertinence of PPI prescription was analyzed in 20 randomly selected medical records. Data are expressed in defined daily dose (DDD). Results: After one year, a 35.5% decrease in oral PPI consumption was noted (901±211 before vs 581±235 DDD, after, P <0.05). A similar trend to a decrease in intravenous PPI consumption was observed (40±23 vs 22±26, P =0.06). During the same period, the overall incidence of severe gastric complication remained stable. The PPI prescription was pertinent in 85% of selected medical records. Conclusion: This study confirmed the interest of professional practice evaluation protocols to improve PPI prescription. A strong implication of all medical staff members is mandatory to maintain such benefits over time. [Copyright &y& Elsevier]

Abstract: Objectives: A prophylactic anti-emetic strategy should depend on the number of nausea and vomiting risk factors. This study was undertaken to evaluate the practices of postoperative nausea and vomiting (PONV) prevention practices among obstetrician-gynaecologists, anaesthetists. Study design: A prospective, self-administered questionnaire survey was emailed to all Club d’Anesthésie Réanimation Obstétricale (Caro) members (French Obstetric and Gynaecology Anaesthetists’ Association). Methods: The questionnaire had closed-ended questions to evaluate each Caro member''s prophylactic anti-emetic practices. Questions concerned demographic datas, prophylactic anti-emetic drugs administered to the patients with or without well known risk factors for developing PONV, the existence of protocol to prevent PONV in their own department of anaesthesiology and their awareness of the existence of French Society of Anaesthesia and Intensive Care (Sfar) PONV prevention guidelines 2007. Results: Of 115 questionnaires, 66 respondents (57%) returned the questionnaires. Most of the respondents (74%) worked in a university hospital. Forty-two percent practiced exclusively in obstetric-gynaecology department. Fifty-six percent were anaesthetists for more than 20 years. Eighty-five percent of the physicians were well-informed about the SFAR''s PONV prevention guidelines. Thirty seven percent of respondents assessed Apfel score systematically for all their patients. The percentages, which didn’t calculate the probability of PONV with Apfel score or calculated only in cases of PONV history or travel sickness were 18% and 45% respectively. In cases of two or more risk factors, 63% used droperidol, dexamethasone and ondansetron in double or triple combinations. Conclusions: Although most surveyed practitioners were well informed about the new guidelines concerning PONV prevention, 27% not follow these guidelines regarding the administration of anti-emetic drugs. The calculation of Apfel score in the preoperative period must be also strengthened. [Copyright &y& Elsevier]

Abstract: Objective: To evaluate the risk of over-inflation of endotracheal tube cuffs (ETC) when used with nitrous oxide (N2O); to assess the rate of under and over-inflation of ETC when they are inflated without a manometer; to survey anesthesiologists about how they prevent these risks. Methods: Nine types of endotracheal tube were studied on bench using various N2O concentrations; airway pressure levels and two sizes of trachea. Then, the rate and magnitude of over and under inflation pressure of ETC was assessed in our clinical practice. Finally, a national survey assessed how anesthesiologists prevented misuse of endotracheal tube with N2O. Results: Pressure in ETC rose sharply using N2O, up to more than 40cmH2O in six over nine tube types. Only two tube types (Mallinckrodt™ Hi-Lo Brandt® and Lanz®) were immune regarding N2O. Pratice study showed that ETC over inflation (>30cmH2O) and under inflation (<20cmH2O) was observed in 50 and 31 % of patients, respectively when cuff was inflated without a manometer. In France, a minority of anesthesiologists inflated ETC with a manometer (41 %) because in 61 % of theatres only manometers were available. Conclusion: There are risks induced by the use of N2O with tracheal tubes. This study provides data to sensitize users to these risks. [Copyright &y& Elsevier]

Abstract: Background: Controls performed at the opening of the operating room include the anesthesia machine auto-test. Omitting the preoperative checklist is unsafe for the patient and increases the risk of possible breakdowns. The purpose of this study was to evaluate the incidence and the situations in which the auto-test of the machine was not performed at the opening of the operative room. Methods: From a database including 55 195 cases between 1st January 2002 and 31st July 2009, a query identified cases in which the auto-test of the anaesthesia machine was omitted and the cases in which anaesthesia was made in spite of the failure of this test. Clinical circumstances were analyzed and anaesthetist and/or nurse anaesthetist were identified from the computerized anaesthesia record. Results: One hundred and ninety cases (1.24%) were identified. Seventy-three percent of the omissions of the auto-test occurred while on duty whereas 85% of the failures of the auto-test took place at the beginning of the scheduled program. Individual factor was identified since three anaesthesiologists out of 22 were responsible for 49% of omissions on duty and one nurse anesthetist was responsible for 18% of the use of a failed machine and 30% of the omission of the auto-test. Conclusion: The auto-test of the anesthesia machine was correctly made in most cases but there are still situations where the checklist wasn’t carried out. Therefore, the human factor seems important and justifies to be taken into account. [Copyright &y& Elsevier]

Abstract: We describe a case of late post-partum haemorrhage from uterine artery pseudo-aneurysm secondary to the vascular trauma induced by a previous caesarean section. This rare aetiology should be known by anaesthesiologists since treatment by arterial embolization is safe and effective whereas curettage usually recommended for primary post-partum haemorrhage can aggravate the bleeding. This diagnosis should be considered in front of late genital bleeding without obvious cause and lead to perform a sonographic examination with Doppler-scan before diagnostic and therapeutic arteriography, eventually preceded by diagnostic MRI. [Copyright &y& Elsevier]

Abstract: Objective: To compare the number and the cost of preoperative tests ordered before scheduled surgery before and after implementation of local guidelines. Study design: Observational retrospective survey. Patients: All patients scheduled in seven surgical specialties. Methods: All preoperative tests ordered during a 1-week period (2008) were noted. Local guidelines based on published guidelines and validated by anesthesiologists of the hospital were then implemented. A second audit was performed 1 year after (2009). Results: Eighty-five and 79 patients’ files were analyzed in 2008 and 2009, respectively. On average, half (46% in 2008 and 58% in 2009) of prescriptions did not follow the guidelines, with anaesthesiologists prescribing more than their own recommendations. Overall conformity to the local guidelines did not improve between 2008 and 2009. However, EKG (79% vs. 95%, p <0.05) and serum electrolytes (72% vs. 99%, p <0.05) ordered were significantly in better agreement with the guidelines. Costs associated with inadequate orders were divided by 2.4 in 2009. Conclusions: Existing practice is overall poor. Non-compliance of preoperative testing to guidelines is a significant cause of uncontrolled cost. Change in compliance is a slow process. [Copyright &y& Elsevier]

Abstract: Obstructive sleep apnoea (OSA) syndrome in adult is defined as an Apnoea-Hypopnoea Index (AHI) of 5 or more per hour of sleep in a context of excessive daytime sleepiness and snoring. OSA is considered as mild with an AHI of 5–15, moderate with an AHI of 15–30, and severe with an AHI greater than 30. OSA is a highly prevalent disease since it should affect 7–15% of the middle-aged population, but most patients are not yet diagnosed for OSA. Middle age, male gender, obesity and arterial hypertension are main risk factors for OSA in adults. OSA patients are exposed to higher neurological and cardiovascular morbidity, including stroke, depression, hypertension, coronary artery disease, heart failure, arrhythmias. Because OSA may lead to life-threatening problems if undiagnosed, anaesthesiologists should be aware of their screening role in the preoperative period. In that way, the STOP-BANG questionnaire is a well-adapted instrument to screen patients for OSA during the preoperative visit. OSA patients are exposed to higher preoperative morbidity in relation with OSA severity, particularly difficult manual ventilation with mask, difficult tracheal intubation and postoperative upper airway obstruction. The unknown diagnosis of OSA is one major contributor to facilitate the occurrence of those events. In the postoperative period, early resuming continuous positive airway pressure and installing the OSA patient in a nonsupine position could be effective in preventing pharyngeal obstruction. Considering the timing of postoperative complications, a careful monitoring in the post-anesthesia care unit for threehours is an appropriate strategy for a majority of OSA patients. Alternatives to opioids should be promoted for postoperative pain control. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To evaluate the impact of the anxiety level using Spielberger test on axillary block success. Study design: Prospective double-blind study. Patients and methods: An axillary brachial plexus block was performed with a nerve stimulator for all patients undergoing elective or emergency upper limb surgery. Spielberger test result was blinded for both patient and anaesthesiologist performing the block. Time to perform the block (minutes) was measured. Anxiety and pain scores were assessed, using a numeric scale (NS), at different time. Successful block was defined as complete sensory blockade combined with painless during surgical incision. Data were compared using Spearman test and multivariate logistical regression analysis. Results: Patients (184) were included (elective surgery=62%; emergency=38%). Failure rate was 10%. On multivariate logistical regression analysis, time to perform the block and NS anxiety score before starting the block were associated with block failure. Spielberger score correlated with NS anxiety score before puncture (Rho = 0,586, p <10−4). Anxiety level was increased in emergency context. Conclusion: Patient''s anxiety level before axillary brachial plexus block is a risk factor of failure, especially in emergency condition. We suggest anesthesiologists to evaluate patient anxiety prior to block performance. A specific anxiolytic treatment may be recommend in some cases. [Copyright &y& Elsevier]

Abstract: The aim of this synthesis was to give recommendations on the use of jet-ventilation during ENT surgical and endoscopy procedures. Literature was collected from PUBMED and analysed by the members of French association of anaesthesiologists in ENT surgery, all skilled in this field. Presentation of these recommendations was given during the general assembly held in Reims the May 15th 2009. Jet-ventilation is especially indicated during upper airway endoscopy and laryngeal invasive endoscopic surgery. Furthermore, transtracheal jet ventilation is included on most of difficult oxygenation and difficult intubation algorithm. The main risk of jet-ventilation is pulmonary barotrauma when expiration of injected gas is impeded by an upper airway obstruction. Failure and complications of tracheal puncture are rare when performed by experimented operators. Clinical use of jet ventilation requires a dedicated device. Practice of jet ventilation without intubation may be dangerous when applied without control of driving pressure and end expiratory tracheal pressure. Every anaesthetist should be familiar with transtracheal ventilation since they may face a “cannot ventilate cannot intubate” situation. Upper airway endoscopy and laryngeal surgery are the ideal field for training jet ventilation, even more so as this technique offers perfect operative conditions. To apply this project, jet ventilation should be used more frequently in routine practice. To maintain skill, regular use of these techniques is required. [Copyright &y& Elsevier]

Abstract: Objectives: One objective is to state more accurately the difficulties met by the anaesthesiologists in an emergency context in case of withholding or withdrawing life sustaining therapies. Study design and participants: A questionnaire addressed to anaesthesiologists of nine hospitals in the extreme West part of France. Materials and methods: The questionnaires were sent and returned by mail in order to guarantee confidentiality. Results: The participation rate was 40% with 172 questionnaires analysed. Ninety-eight per cent of the anaesthesiologists have already participated in a withholding or withdrawing life sustaining treatments, and in an emergency context in 92% of the cases. In that last case, criteria related to the severity of the clinic presentation and to the short-term death probability influence the decision made to interrupt life-sustaining therapies. For 93% of anaesthesiologists, the decision should be collegial, but 50% of them had already made such a decision alone. The withdrawal of ventilatory support was the most difficult decision to make. Withdrawing mechanical ventilation or extubating appeared impossible for 23.4 and 50% of the anaesthesiologists respectively. Providing comfort care to the patients with end of life decision was essential for 100% of the anaesthesiologists, but 11% of them used and considered analgesic and sedation after withholding or withdrawing life sustaining treatments as euthanasia. The complaint possibility worried 57% of the anaesthesiologists and influenced the writing of the process or giving information to the families respectively for 65 and 75%. The righting of the medical files could be improved for 92% of the anaesthesiologists. Conclusion: The decision of withholding and withdrawing life sustaining treatments in an emergency context is based on the conviction of short-term death probability. Withholding and withdrawing life sustaining treatments is a decision made according to the principles of collegiality and necessary comfort cares, but the procedure can still be improved, especially in the redaction of the medical file and the ethical and juridical control of these extreme situations. [Copyright &y& Elsevier]

Abstract: To determine neuraxial anesthesia practices in obstetric departments in Languedoc-Roussillon in parturient with large lumbar tattoo covering the puncture area. “A prospective anonymous survey was sent to anaesthesiologists” including a clinical case scenario with a tattooed woman. Questionnaire included items on neuraxial anaesthesia in various circumstances, reasons for the decision process, and “consensus management” or not “within the unit”. Fifty-four anaesthesiologists answered (response rate: 57%). Fifty-seven percent would perform an epidural anaesthesia (EA) through the tattoo. Thirty-nine percent would not; among which two third only would propose an alternative for EA. Elective or emergency caesarean section would prompt most of the anaesthesiologists to perform a spinal anaesthesia, especially in parturients with Mallampati Class III (93%) versus Class I (70%) airway. Seventy percent of responders reported no consensual management in their unit. Our study illustrates this lack of consensus in obstetrical units and among anaesthesiologists along with a variable attitude linked with the obstetrical and anaesthesiological situation. [Copyright &y& Elsevier]

Abstract: We report a case of per anaesthesia malignant hyperthermia (MH) arisen in a 16-year-old young man presenting antecedents of five anaesthesia with use of halogenated agents without complication and having started a typical crisis of MH after five hours of anaesthesia with sevoflurane and with recurrence of the crisis after 14hours in ICU. The association in the same clinical case of these three peculiarities of the crisis of MH already described separately in the international literature allows us to insist on their importance, with the French-speaking anaesthesiologists community. [Copyright &y& Elsevier]

Abstract: Introduction: The American College of Cardiology/American Heart Association (ACC/AHA) guidelines stratify perioperative cardiac risk according to clinical markers, functional capacity, and type of surgery. They help determining which patients are candidates for preoperative cardiac testing and optimizing the cost-effectiveness of the evaluation strategy. Auditing our preoperative anaesthetic screening practice revealed an exceedingly high rate of referrals to the cardiologists. A small pocket-size reminder was created in order to improve the adhesion of the anaesthesiologists to the recommendations of the ACC/AHA, and confirm or obviate the need for a formal preoperative specialized cardiology consultation. Another audit was conducted 1 year later in order to evaluate the effectiveness of this reminder. Methods: The second audit was conducted over a period of 1 month. Recorded data included demographic characteristics, clinical predictors of cardiovascular risk, surgical risk, and the reasons for the cardiac evaluation by a cardiologist (as reported by the senior or junior anaesthesiologist). Results of this second audit were compared to those of the audit conducted a year earlier. Results: During the first audit, a total of 654 patients were seen in the preoperative unit. Fifty-two patients were referred to a cardiologist during the study period (7.9%). Guidelines for cardiac assessment were respected in 7/52 patients (13.5%). During the second audit, 30 out of 787 patients (3.8%) screened in preoperative anaesthetic consultation unit were referred to the cardiologist. According to the ACC/AHA guidelines, 27/30 patients (90%) objectively needed a cardiology consultation due to the existence of a known previous heart disease. Discussion: The use of the pocket reminder concerning the ACC/AHA recommendations significantly reduced both the total number of cardiology referrals, and the number of unjustified referrals. The use of a pocket guide may help in reducing both the cost and the postponement of scheduled surgery. [Copyright &y& Elsevier]

Abstract: Objectives: This article summarizes functioning and results of anaesthesia adverse effects reporting system over its first 18 months, from August 2006 to February 2008. Study design: Monocentric retrospective study. Methods: Reporting system is available 24/24h, 7/7 to every employee with an individual password. A committee with anaesthesiologists, nurses and risk management engineer examines every notification by two months. We evaluated number of reports, type of reporter, type of dysfunction reported and solutions. Numerical data are compared with a Student t test or X 2 test. A p-value of less than 0.05g being considered as statistically significant. Results: One hundred and eighty-five reports were registered for the first 18 months (1% of anesthesia activity) with a slowdown with time (p =0.02). Eighty-six percent of the statements were made by anesthesiologists, but some physicians had never reported. Malfunctions shared between different services (identity, operating room organisation) are rarely solved (67%) compared to specific anesthesia problems (93%) (p <0.001). Conclusion: The reporting system is simple and available but some professionals don’t declare, generating reporting bias. This network underlines major general dysfunctions (identity) but ways to solve are limited to date. [Copyright &y& Elsevier]

Abstract: Objective: The Natural Killer cells (NK) are an important part of non-specific cellular-mediated and antitumoral immunity. The goal of this review is to recapitulate data published over NK activity during the perioperative period and the influence of anaesthesia, analgesia and modulation of sympathetic system. Data sources: Pubmed/Medline database. Study selection and data extraction: Keywords-based selection, without limit of date: fundamental studies, randomized controlled trials and non-randomized comparative studies. Data synthesis: In human as in animal studies, an important correlation exists between NK activity and prognosis linked to the development of metastasis. The great depression of this cytotoxicity during the perioperative period could be able to compromise host defenses. The influence of anaesthetics and analgesics is important. The effects of the opioids, the agonists and the antagonists of the sympathetic nervous system, the prostaglandins, the NSAIDs, the ketamine, the hypnotics and the locoregional anaesthesia are systematically reviewed. The limits of experimental model presented are covered. Conclusion: The effects of anaesthetic/analgesic drugs and techniques, the consequences of sympathomodulation on NK activity are numerous and sometimes opposite. It is important for the anaesthesiologist to keep in mind that the long term consequences of his techniques on the patients’ outcome must be clarified. [Copyright &y& Elsevier]

Abstract: Ultrasound has become a daily practice for anesthesiologists for central venous catheterization and regional anaesthesia, but also for the diagnosis of pleuro-pulmonary, cardiac, and vascular diseases; this is illustrated by our observation. We report a case of a cirrhotic patient who underwent emergency surgery for a Colle''s fracture under ultrasound-guided supraclavicular block which was complicated by acute dyspnoea. The use of ultrasound in the operating theater has revealed hepatic hydrothorax which occurred during a diaphragmatic paralysis secondary to the blocking of phrenic nerve due to the regional anaesthesia. [Copyright &y& Elsevier]

Abstract: Introduction: Recently, the French Society for Anaesthesia and Intensive Care (SFAR) has updated algorithms for difficult airway management, in which, the place of the intubating laryngeal mask (ILMA) is well defined. Moreover, in the guidelines, the SFAR recommended that the training for the different techniques for difficult intubation should initially be achieved on manikins. However, few data are available for disposable ILMA learning process on manikins. Study design: To compare, on manikin, the learning curves of the disposable and reusable ILMA. Materials and method: Forty operators (anaesthesiologist, nurse, resident), experienced with conventional tracheal intubation but novice to commercially available ILMAs (Sebac, Pantin, France), underwent videotape learning and manikin training. After randomisation, each participant had to perform 10 timed consecutive tracheal intubations with either reusable or disposable ILMA. The learning curve was built according to the duration of successful procedure. Failure was considered if tracheal intubation could not be achieved or if the procedure lasted more than five minutes. Results: No difference was noted between the two groups in terms of learning curves, number and repartition of the failed attempts during the learning process. Conclusion: This study shows that both disposable and reusable ILMA share similar learning process on manikins. Further studies are needed to evaluate the efficiency of the disposable ILMA in the clinical field of difficult intubation. [Copyright &y& Elsevier]

Abstract: Immediate hypersensitivity reactions occurring during anaesthesia, whether IgE-mediated or non IgE-mediated, remain a major cause of concern. The authors report results from an eight-year survey conducted by the GERAP. From 1 January 1997 to 31 December 2004, 2516 patients who had experienced an immediate hypersensitivity reaction were included in this survey. A non-IgE mediated reaction was diagnosed in 700 cases (27.82%) and an IgE mediated reaction in 1816 cases (72.18%). The most common causes were neuromuscular blocking agents (n =1067, 58.08%), latex (n =361, 19.65%) and antibiotics (n =236, 12.85%). The results were significantly different in children: latex was incriminated in more than 50% of the cases, followed by neuromuscular blocking agents (39%) and antibiotics (10.2%). The data showed a female predominance in adults but not in children, whatever the mechanism of the reaction. These results emphasize the need for systematic screening in case of an immediate hypersensitivity reaction during anaesthesia and for the development of centres specializing in perioperative allergies capable of providing expert advice to anaesthesiologists and allergists. [Copyright &y& Elsevier]

Abstract: Whether you are an aficionado or completely uninitiated, everyone has an opinion on bull-fighting. The bull-fighter is in constant risk of injury. A medical team made up of surgeons, anesthetists, emergency physicians and nurses remains present throughout the show. For the anaesthetist and surgeon, a wounded bullfighter is an emergency because the vital and functional prognosis are engaged. The team must act in conformity with normal practice and the Code of Medical Ethics because any lack of coordination between the practitioners is punishable by law in the same way as technical fault. Several specific aspects of this type of medical procedure should be highlighted: firstly, the legal restrictions within the corrida, and secondly, the nature of the medical team, which may be comprised of doctors normally based within a public health institution and others who practice in a private health establishment. The particularity of the situation reveals differences in the system of liability, and civil liability must be distinguished from administrative liability: both of these allow the victim to obtain compensation for harm caused, but the consequences of each are different according to doctor status. The fact that the anaesthetists frequently work on a voluntary and benevolent basis does not exonerate them from liability. Lastly, a question frequently addressed is whether or not the doctor is covered by his professional insurance when he is on ringside duty. [Copyright &y& Elsevier]

Abstract: Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation. [Copyright &y& Elsevier]

Abstract: Study design: The aim of this study was to assess how French anaesthesiologists perform continuing medical education (CME). Methods. – A 73 items survey was mailed to 1,000 anaesthesiologists (11% of anaesthesiologists population) of geographic, gender and institution representative of national anaesthesiologist demography. A second mail was sent to non-responders, 6 weeks later. Results. – The answer rate was 40.8% and the sample of responders appeared to match the French anaesthesiologist population. Seventy-two percent of surveyed anaesthesiologists were affiliated to the French society of anaesthesia-intensive care and 24% to other medical societies. Attendance to French congresses was 81% and miscellaneous congresses were equally appreciated in terms of quality. Only 17% of surveyed anaesthesiologists attended international congresses. Multi-thematic congresses were preferred by 67%. The annual time devoted to congresses was 6 days (median) with additional 4 days (median) reserved for practical courses. French medical journals and international journals had a reading rate of 89 and 37%, respectively. For 61% of responders CME was funded by institutional grants. Internet CME use was found in 73% of anaesthesiologists. Time and money were the two most frequent reasons invoked for CME restriction. Conclusion. – CME is a broadly shared activity, which still remains focussed on national resources. [Copyright &y& Elsevier]

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Objectives: Fears related to the future of anaesthesia manpower in France have led the French College of Anaesthesiologists (Cfar) and the French Society of Anaesthesia and Intensive Care (Sfar), in scientific partnership with the National Institute for Demographic Studies (Ined), to set-up a national survey among French anaesthetists (MAR) practicing in France, to describe their demographic evolution and to analyse their professional activities.Methods: The survey was based on a personal questionnaire, filled by each individual, approved by the National Commission on Informatics and Freedoms (CNIL). The survey was conducted in November 1998, in the 1484 hospitals, public (590) and private (894) where anaesthetics are performed, under the control of local and regional referents.Results: The anaesthesiologists positions count gave a total of 9741 positions shared between 5694 in public practice (58%), 3569 in private practice (37%) and 478 in private hospitals taking part to the national health service-PSPH (5%). The evaluation of the number of anaesthesiologists from the number of positions has made necessary a methodology of rectification of the survey to take in account the lack of response and the multiple sites of activity. The survey allows an evaluation of around 8876 physicians practising anaesthesia and intensive care in France at the beginning of 1999, among them 216 overseas. This census is in concordance with the count made by the Medical Council—Ordre des me´decins—which published a number of 8716 anaesthesiologists in France, and 234 overseas, at the 1st January 1999, corresponding to a total of 8950. The annual demographic growth has felt from 9% per year, before 1989, to reach the level zero, in 1999. The masculinisation of the speciality is growing with a proportion of 35.7% of females, as well as ageing, the overage of age increasing from 42.8 in 1989 to 45.9 years in 1999. The pyramid of ages does not correspond to a growing population but to ageing people due to a decrease of the youngest classes. The medical density of 14.75 anaesthesiologists for 100 000 inhabitants in 1999, compared to 12.9 in 1989, is slightly above the European average, but the geographic distribution is very unequal between north and south, the large cities, centre of a university hospital, and the smaller one even if a reduction of differences is observed. The study and the analysis of professional activities bring important data to take in account side of demographic evolution.Conclusion: The demographic evolution must integrate non-only the reduction of the entries in the speciality, of the retirements, but also the sociological evolutions linked to the working time reduction. The solutions face to the promised shortcut of manpower consist of a reorganisation of the structures, a new definition of tasks and managements, without the possibility to avoid and adjustment of the anaesthesiologists population. [Copyright &y& Elsevier]

Abstract: For painful procedures in children, national recommendations are now available in France. When sedation-analgesia with nitrous oxide/oxygen mixture fails, in order to perform a painful procedure under good conditions, low dose ketamine (IV bolus titration 0.5mg/kg but not more than 2mg/kg) is the only drug potentially used by a trained physician, without the presence of an anaesthesiologist (Grade A). With these dosages without drug combination, the highest level of security depends largely on the quality of the hospital environment (Grade A). Intramuscular (<4 mg/kg) is an alternative route, but the recovery time is delayed (Grade B). The optimal management is performed by an anesthesiologist, it is necessary to facilitate access to the operating room for children undergoing this type of procedure (Professional consensus). Mainly IV ketamine can be used by pediatric intensive care and emergency physicians who currently have medical skills to detect and treat side effects. [Copyright &y& Elsevier]

Abstract: We report the case of a patient who received a wrong side iliofascial block immediately before being operated for a femoral neck fracture. This error did not lead to any adverse consequence but this case confirms that wrong side or wrong site error can also occur in anaesthetic practice, especially in emergency procedures, and is not only confined to surgical practice. Anaesthesiologists should be careful when performing unilateral procedures and implement similar strategies than those used by surgeons. [ABSTRACT FROM AUTHOR]

Abstract: Ultrasound imaging is a major technological advance in the practice of regional anesthesia. For the social security, their rationale relies on the concept of a global medical act i.e., each medical act is worked out, in order to describe the realized medical act totally. At present the social security uses this concept to prevent the anesthetists from quoting a supplementary ultrasound act. In this article we discuss the legitimacy of quoting ultrasound-guided regional anaesthesia. [ABSTRACT FROM AUTHOR]

This article reports the case of a 31 years old man who suffered from an acute pulmonary oedema after laryngospasma following extubation. This pathology, better known by anesthesiologists than internists, results primarly from a rapid rise in negative intrapleural pressure. It is not associated with previous cardio-pulmonary illness and has a begnin course with resolution within 48 hours with oxygen and positive end expiratory pressure support. [ABSTRACT FROM AUTHOR]

Abstract: Intracerebral hemorrhage remote from the site of surgery is an infrequent complication after neurosurgical procedures. Cerebellar hemorrhage after supratentorial craniotomy is the most commonly described pattern of remote hemorrhage unknown by the anesthesiologist. It is linked with a frequent morbidity and mortality. We report a case of this complication after meningioma surgery with a favorable outcome. [Copyright &y& Elsevier]

Surgery for emphysema is considered as one of the most challenging procedure for anaesthesiologist. Because of the critical illness of such patient, perioperative monitoring is important. Ventilatory monitoring is often difficult or impossible due to a possible massive air leak during the procedure. This case described how ETCO2 was assessed by capnography monitoring on the chest tube drainage. [Copyright &y& Elsevier]