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Resume L’intelligence humaine produit constamment des erreurs, mais dispose egalement d’une grande capacite a les detecter et a les corriger. Le travail en equipe implique des competences non techniques (communication, leadership, prise de decision) qui peuvent egalement etre a l’origine d’erreurs. Les situations critiques sont responsables d’un stress qui decuple la production d’erreurs et la difficulte a mobiliser les connaissances. Les progres pour la securite des patients ont conduit a la mise en place d’outils de type aides cognitives (AC) (ou check-lists, fiches urgences…) : face a une situation de crise, les informations sont structurees, pas a pas, au plus pres de l’evenement, avec l’objectif d’ameliorer la performance de l’equipe medicale et paramedicale en guidant le raisonnement, listant l’enchainement des actions et evitant l’oubli d’etapes. Un des membres de l’equipe a pour role de la lire a haute voix pour guider les actions du reste de l’equipe. La litterature montre que l’utilisation de ces outils est efficace en simulation pour ameliorer la prise en charge d’une crise au bloc par l’equipe d’anesthesie, comme dans d’autres champs d’activites medicales. Ces AC sont des outils dont la conception (simple et claire), la mise en place (formation et simulation), la disponibilite (toujours disponible), le support, le format et l’appropriation sont essentiels. L’enseignement de leur utilisation en simulation est fondamental. La SFAR, via le Comite d’analyse et maitrise du risque (CAMR), participe a cette evolution en produisant ses AC sur la gestion des situations critiques en anesthesie et en reanimation (disponibles sur le site : https://sfar.org/espace-professionel-anesthesiste-reanimateur/outils-professionnels/boite-a-outils/aides-cognitives-en-anesthesie-reanimation/ , et sur l’application mobile de la SFAR).

Aim The increasing use of high-fidelity simulation is limited by the imbalance between the growing number of students and the human resources available in such a way that all residents cannot play a role during scenarios. The learning outcomes of observers need to be studied. Methods This prospective randomised study was approved by the institutional review board. Anaesthesia residents attending a one-day training session were enrolled. In each of the four scenarios, three residents played an active role while others observed in a separate room. All participants attended debriefing sessions. Residents were randomised between active participant-observer group (AP-O group) and observer group (O group). A similar questionnaire was distributed before, immediately after the session and after three months and included self-reported assessment of satisfaction, medical knowledge (noted 0–16), and non-technical skills. Results A hundred and four questionnaires were analysed. Immediately after the simulation, a significant increase in medical knowledge was recorded but was higher in the AP-O group (6 [5–8] to 10 [8–11]/16) than in the O group (7 [5–8] to 9 [7–10]/16). High scores for non-technical skills were similarly observed in both groups. Satisfaction was high in both groups but was higher in the AP-O group (9 [8–9] versus 8 [8–9]/10, P = 0.019). Decay of knowledge was observed for most main outcomes at three months. Conclusion This study suggests an immediate improvement of learning outcomes for both roles after immersive simulation but some learning outcomes may be better for residents engaged as players in scenarios.

Resume En anesthesie pediatrique, la simulation a un interet certain pour l’apprentissage de la gestion des complications frequentes ou rares, mais aussi pour la formation continue. Elle est egalement utile pour la pratique de l’anesthesie-reanimation pediatrique soit reguliere soit peu frequente. Selon l’experience de l’anesthesiste-reanimateur qui y participe, elle permet l’apprentissage et l’amelioration des competences medicales et non techniques de la gestion d’une situation de crise.

Introduction. The use of cognitive aids (CAs) during critical events is thought to be useful. However, whether CAs are known and used by French and Canadian anaesthesia providers is not clear. Methods. A survey was emailed to French and Canadian anaesthesia providers in 2017 through their respective national societies. It consisted of 23 questions about the participants’ demographics and their knowledge, use, and impact of CAs. A second survey was sent to French simulation centres. Results. 912 responses were recorded in France and 278 in Canada (overall response rate: 7% and 11%, respectively). Among the respondents, 700/899 in France (78%) versus 249/273 (91%) in Canada were familiar with the concept of cognitive dysfunction during a crisis and 501/893 (56%) in France versus 250/271 (92%) in Canada knew the concept of CAs. Amongst those respondents who knew about CAs, 189/492 (38%) in France versus 108/244 (44%) in Canada stated that they had already used a CA in real life and 225/493 (45%) in France versus 126/245 (51%) in Canada had received training in their use. Simulation was the principal modality for training in 150/225 (67%) of cases in France versus 47/126 (37%) in Canada. Among the 28/50 French simulation centres which responded (2018 January), 27 organised sessions in anaesthesia and 22 used CAs. Conclusion. CAs were better known in Canada than in France, but their actual use in real life was low in both countries. Simulation appears to play a potentially important role training anaesthesia providers in the use of CAs.

In this prospective observational study, we compared changes in cardiac index (CI) during fluid challenge using photoplethysmography (PPG; Nexfin™) (CIPPG) versus esophageal Doppler (ED) (CIED) in major noncardiac surgery patients.Measurements were obtained when the attending anesthesiologist decided to perform a fluid challenge. Correlations with linear regression, Bland-Altman analysis, and analysis of covariance were performed. Trending ability was studied using 2 different methods: a 4-quadrant plot and a polar plot.Forty-three patients were analyzed with a total of 111 fluid challenges. There was a significant linear relationship between CI PPG and CI ED (r2 = 0.34; P0.001). The bias between the ED and the PPG measurements of CI was -0.114 (95% confidence interval [CI95], -1.9 to 1.7) L/min/m2, with a mean percentage error of 55%. The correlation between the changes in CI during a fluid challenge was significant (r2 = 0.25; P = 0.002). The concordance rate of directional changes (increase or decrease) of CI PPG and CI ED during fluid challenge was 67% (CI95, 57-75) for the whole data set and 85% (CI95, 70-94) with an exclusion zone of 15%. When considering ED as a reference, the sensitivity and specificity to give an additional bolus with PPG (increase in CI PPG ≥ 15%) were 35% (CI95, 19-55) and 90% (CI95, 81-96), respectively, with a positive predictive value of 58% (CI95, 33-80) and a negative predictive value of 78% (CI95, 68-86).In major noncardiac surgery patients, the evaluation of CI using PPG is not interchangeable with the evaluation of CI using ED. When considering the ED as an accurate device to assess changes in CI, PPG is not appropriate to assess the need for additional fluid administration. These results clearly indicate the limitations of PPG as an accurate device to track changes in CI compared with ED.

Introduction L’AFGSU2 est une formation aux gestes d’urgence obligatoire chez les etudiants en medecine. Dans notre Faculte, elle est organisee avec une journee initiale en 2 e annee (DFGSM2) puis un rappel en 4 e annee (DFASM2). L’objectif est d’evaluer l’efficacite de la formation AFGSU2 chez les etudiants en medecine et le niveau de retention a 1 et 2 ans. Patients et methodes Tous les etudiants de DFGSM2 ont ete inclus dans cette etude monocentrique lors de la formation AFGSU2. Un meme questionnaire comportant 12 questions a choix simple et/ou multiple a ete rempli avant (T1) puis apres (T2) la formation initiale en 2 e annee puis a ete rempli a 1 an (T3) puis a 2 ans (T4) apres la formation. Les resultats sont rapportes comme mediane [espace interquartile] ou pourcentage. Les statistiques etaient non parametriques. Resultats En janvier 2013, 131 etudiants de 2 e annee ont participe a l’AFGSU2 avec 128 reponses au questionnaire a T1 et 131 reponses a T2. En janvier 2014, 119 etudiants en 3 e annee ont repondu au meme questionnaire a T3 et en janvier 2015, 129 etudiants en 4 e annee a T4. La mediane des notes s’ameliore significativement de T1 a T2 ( p p p Pour la question sur le numero du SAMU, on retrouve un tres fort taux de bonne reponse a T1, T2, T3 et T4 (96 % ; 86 %, 96 % et 97 %, respectivement). Concernant les questions sur la prise en charge de l’arret cardiaque ( Fig. 1 ), on observe systematiquement une forte amelioration entre T1 et T2 (Q2 : 74 a 97 %, Q3 : 44 a 82 %, Q4 : 16 a 60 %, Q5 : 18 a 97 %, Q6 : 20 a 89 %, Q7 : 3 a 42 % et Q8 : 10 a 82 %, p p p p p Discussion Cette etude montre une forte amelioration des reponses immediatement apres la formation AFGSU2 puis une diminution partielle de la retention des connaissances a 1 ans qui s’ameliore a nouveau a 2 ans. La retention reste globalement satisfaisante probablement due a la poursuite de la formation des etudiants a la fois theorique (examen de cardiologie avant T4) et pratique (stages). La formation relative a l’arret cardiaque semble satisfaisante alors que celle sur l’obstruction des voies aeriennes pourrait etre amelioree lors du rappel a 2 ans.

Urgent tracheal intubations are common in intensive care units (ICU), and succinylcholine is one of the first-line neuromuscular blocking drugs used in these situations. Critically ill patients could be at high risk of hyperkalemia after receiving succinylcholine because one or more etiologic factors of nicotinic receptor upregulation can be present, but there are few data on its real risk. Our objectives in this study were to determine the factors associated with arterial potassium increase (ΔK) and to assess the occurrence of acute hyperkalemia ≥6.5 mmol/L after succinylcholine injection for intubation in the ICU.In a prospective, observational study, all critically ill patients intubated with succinylcholine in an ICU were screened. Only intubations with arterial blood gases and potassium measurements before and after (K(after)) a succinylcholine injection were studied.During 18 months, 131 critically ill patients were intubated after receiving succinylcholine with arterial potassium before and after intubation (K(after)) for a total of 153 intubations. After multivariate analysis, the only factor associated with ΔK was the length of ICU stay before intubation (ρ = 0.561, P0.001). The factors associated with K(after) ≥6.5 mmol/L (n = 11) were the length of ICU stay (P0.001) and the presence of acute cerebral pathology (P = 0.047). The threshold of 16 days was found highly predictive of acute hyperkalemia ≥6.5 with 37% (95% confidence interval: 19%-58%) of K(after) ≥6.5 after the 16th day compared with only 1% (95% confidence interval: 0%-4%) of K(after) ≥6.5 when succinylcholine was injected during the first 16 days.This study shows that the risk of ΔK after succinylcholine injection is strongly associated with the length of ICU stay. The risk of acute hyperkalemia ≥6.5 mmol/L is highly significant after 16 days.

BACKGROUND: The aim of this study was to reevaluate the efficacy of tramadol for postoperative analgesia and to determine its ED 80 (the clinical dose for which 80% of the patients had their pain adequately relieved) using the Continual Reassessment Method. Because the preliminary results of the first 24 patients were contradictory to the literature, we performed a second trial to verify and validate our data. METHODS: The study was double-blind and prospective. Participants were allocated to a dose of tramadol by 3-patient cohorts, in order of inclusion. The dose of tramadol received in each cohort was determined by the reaction of all previous patients. Five doses were chosen before beginning, with a probability of a positive reaction associated with each: 60 (0.4), 100 (0.55), 140 (0.7), 190 (0.8), and 260 mg (0.9). Tramadol was considered effective if the numeric pain scale was ≥3/10 at T30. RESULTS: The effective dose in 80% of patients was 260 mg for both trials. The probability of success of the 260 mg dose was 0.699 (95% credibility interval, 0.471-0.874) and 0.657 (95% credibility interval, 0.437-0.853) for trial 1 and trial 2, respectively. CONCLUSION: Tramadol used as a sole drug cannot be considered the drug of choice after moderately painful surgery. The doses needed to relieve pain in 80% of patients are much larger than the usual dose of 100 mg. The Continual Reassessment Method allowed us to determine the ED 80 of tramadol with a limited number of patients.

Introduction Compte tenu du nombre important d’internes DESAR, chaque interne ne peut passer qu’une seule fois de maniere active sur un scenario (acteur) puis assiste en tant que spectateur aux autres scenarios lors d’une journee de formation par simulation haute fidelite. Notre objectif etait d’evaluer l’impact du role (acteur ou spectateur) sur l’apprentissage des connaissances medicales des internes. Materiel et methodes Une journee de simulation haute fidelite avec 4 scenarios differents a ete organisee pour les internes DESAR d’Ile-de-France (5e semestre a 7e semestre). Pour chaque scenario, il y avait 3 internes acteurs et les autres etaient spectateurs dans une salle adjacente grâce a une retransmission audio-video en direct. Le debriefing apres chaque scenario etait commun pour l’ensemble des apprenants. Au debut (pretest) puis en fin de journee de simulation (posttest), un test de connaissances medicales a ete rempli par les internes (16 questions soit 4 questions par scenario). Les resultats correspondant au scenario ou ils etaient acteurs « test acteur » (note sur 4) ont ete compares a ceux ou ils etaient spectateurs « test spectateur » (note sur 4). Les resultats on ete exprimes en mediane [espace interquartile] et analyses statistiquement avec un test de Wilcoxon (p Resultats Parmi les 62 internes (70 % en 6e semestre) inclus sur 5 jours de simulation, 3 n’ont pas ete inclus du fait de leur retard. Au total, 59 « tests acteurs » ont ete compares a 189 « tests spectateurs » ( Fig. 1 ). Avant la formation par simulation, il n’existait pas de difference significative entre les resultats du « pretest acteur » et du « pretest spectateur (2 [0–3] vs 2 [1–3], p = 0,50, respectivement) ( Fig. 1 ). Apres la journee de simulation, il n’existait pas de difference significative entre les resultats du « posttest acteur » et du « posttest spectateur » (3 [2–3] vs 3 [2–3], p = 0,48, respectivement) ( Fig. 1 ). En revanche, une amelioration significative des resultats entre avant et apres la simulation pour les deux sous groupes (acteurs et spectateurs) a ete observee (p Fig. 1 ). Discussion Notre etude preliminaire a montre une amelioration similaire des connaissances medicales que l’apprenant soit acteur ou spectateur. Une evaluation de la retention de ces connaissances est prevue a 6 mois par le meme test. Du moins en ce qui concerne les connaissances techniques, le role de spectateur dans une seance de simulation haute fidelite semble aussi benefique sur l’apprentissage des connaissances medicales que celui d’acteur.