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PubMed2003

Trauma care systems in France.

The French Republic includes approximatively 60 millions inhabitants for almost 550,000 km(2). Prehospital management is organised at department level (96). This management involves a regulatory system initiated from a unique phone number (15 national). The medical regulator sends either first-aid providers or a medical team. On-site care is highly developed and prehospital medically assisted care is really the first phase of the treatment of the injured. The team ensures that the victim is in the best condition for transport and participates in monitoring. Intra-hospital care begins either in an emergency room, with a physician qualified in Emergency Medicine, or in a recovery room, with a surgical intensive-care team. There is no specialisation in trauma in France. All specialist surgeons treat those aspects of trauma pathology that concern them. All surgeons operate on trauma patients and with regard to the organ concerned: digestive, orthopaedic, em leader. The challenge nevertheless remains that of maintaining facilities at a sufficient level to deal with everyday pathology, known for the seriousness of its consequences in both human and financial terms, within an increasingly sparse hospital infrastructure. Suggestions are emerging in response to these preoccupations. Organisation at the European level of hand emergency units (FESUM) is a targeted example.

Ambulances↗
PubMedDate not supplied

A comparison of hospital-based charges following partial and radical nephrectomy.

OBJECTIVE: Recent studies demonstrate similar survival rates in patients treated with either partial or radical nephrectomy for renal tumors less than 4 cm. We retrospectively compared the hospital based charges for these two procedures in a similar cohort of patients treated at Memorial Sloan-Kettering Cancer Center. PATIENTS AND METHODS: A retrospective review of 103 consecutive cases of renal tumors less than 4 cm treated by either radical or partial nephrectomy from 1996 to 1999 was conducted. Overall hospital charges were calculated by analyzing 18 separate departmental charge categories including room and board, pharmacy, radiologic tests, operating room charges, and laboratory services. RESULTS: A total of 66 partial and 37 radical nephrectomies were analyzed. No difference was found in the mean charge per procedure ($16,660, partial and $16,545, radical); (p > .05). The major cost drivers for partial and radical nephrectomy respectively were: 1) room and board, 42% and 44%; 2) operating room charges, 28% and 25%; 3) pathology, 6% and 6%; 4) recovery room, 6% and 7%; and 5) biochemistry, 5% and 5%. Significant increases in charges for partial nephrectomy were noted from the blood bank services and intraoperative surgical supplies. The median length of stay (5 days) was identical for partial and radical nephrectomy. No difference was found in the complication rate for these procedures (p > .05). CONCLUSION: Hospital-based charges for radical and partial nephrectomy are similar at when performed at a tertiary care referral center.

Adult↗
PubMed1992

[Isolation of MRSA from inpatients, staff and environment in the hospital].

The state of MRSA contamination of inpatients, hospital staff, and the hospital environment was evaluated. Nasal, pharyngeal, and digital samples from 182 patients admitted in September and October, 1990, and 288 hospital staff members and sputum, urine, and feces of the inpatients were cultured. Environmental contamination was examined in samples collected from the air by air sampling and from the floor by the wiping method. The MIC and the coagulase type of the MRSA obtained were determined, and their relationships were evaluated. MRSA was detected in 9.5% of nasal samples, 7% of pharyngeal samples, 10% of sputum samples, 0% of urine samples, and 2.6% of fecal samples from the 182 inpatients. It was detected in 4% of nasal samples, 0.7% of pharyngeal samples, and 1% of digital samples from the 288 hospital staff members. From the environment, MRSA was detected from hospital rooms of the surgery and neurosurgery wards, the nursing room and corridors of the obstetrics and gynecology ward, and the recovery room of the urology ward. The coagulase type of the MRSA obtained was the primarily type II regardless or whether the samples were obtained from the subjects or the environment. Concerning the drug sensitivity, many MRSA strains were highly resistant to DMPPC and FOM, but the sensitivity to RFP was 0.1 microgram/ml or less in all strains except for one highly resistant strain (200 micrograms/ml or above).(ABSTRACT TRUNCATED AT 250 WORDS)

Air Microbiology↗
PubMed2002

Intraoperative lidocaine injection into the carotid sinus during endarterectomy.

OBJECT: Many surgeons inject a local anesthetic agent into the carotid sinus before carotid endarterectomy in an attempt to ameliorate perioperative hemodynamic instability. The purpose of this study is to analyze the effect of carotid sinus injection with lidocaine on perioperative hemodynamics and complications. METHODS: The authors prospectively studied 92 patients in whom 100 consecutive carotid endarterectomies were performed by a single surgeon (eight procedures were bilateral). Patients were randomly assigned to one of two groups, in which either 0.5 ml of 1% lidocaine was injected into the carotid sinus nerve or no injection of lidocaine was administered before the arteriotomy. All patients were treated postoperatively according to a standard endarterectomy protocol. There were no significant differences between the two groups in the incidence of hypertension, hypotension, or the use of vasoactive medications in the operating room following restoration of carotid artery (CA) blood flow, in the recovery room, or in the intensive care unit. CONCLUSIONS: Injection of lidocaine into the carotid sinus at the time of endarterectomy is not associated with a significant improvement in any hemodynamic factor, from the time of restoration of CA blood flow to postoperative Day 1.

Aged↗
PubMed1995

[Impact of the Hospital Coordinator Program on obtaining kidneys for renal transplantation].

Limited organ supply is currently the major obstacle to the transplantation programs around the world. As an alternative to increase the organ donation rate, we undertook a preliminary transplant coordinator program study, during a 6 month period, in five public hospitals, as part of the National Transplant Program of the Centro Nacional de Diálisis y Trasplante. The primary objective of the Transplant Coordinator Program was donor detection and organ procurement, along with education of the community. Forty five predonors were detected, with an average age of 25.8 +/- 1.6 years, of these, 36 were men (80%). None of them was a voluntary donor. The most frequent diagnoses were cranial trauma in 57.8% and stroke in 22.2% Forty two percent (42.3%) of the predonors were detected in the emergency room, 33.3% in intensive care units and 24.4% in the surgery recovery room. The conversion rate of predonors to donors were 29%. The main causes for not conversion of predonors into donors were: family refusal 44%, sepsis 13%, cardiac arrest 13%, and reduced renal function 6%. In conclusion, the Transplant Coordinator Program allows to increase the predonor detection and gives good information for adequate management of donor and public educational campaign about the subject.

Adult↗
PubMed1998

One-day admission for lung lobectomy: an incidental result of a clinical pathway.

BACKGROUND: Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained. METHODS: Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia. RESULTS: All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome. CONCLUSIONS: We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.

Aged↗
PubMedDate not supplied

Effects of general anesthesia on the human blink reflex.

The blink reflex was studied in 10 patients undergoing elective procedures under general anesthesia. Anesthetic agents were isoflurane, halothane, nitrous oxide, methohexital, and thiopental in various combinations. At induction, blink reflexes were diminished by low-dose thiopental (1-1.5 mg/kg) and abolished by high-dose thiopental (4-8 mg/kg) and methohexital (1.5 mg/kg). Blink reflexes were absent during halogenated volitile inhalational anesthesia and did not return until patients were in the recovery room, well after end-tidal anesthetic levels were zero by mass spectroscopy. Recovery of consciousness and the ability to blink on command often preceded return of any blink reflex activity, indicating that the blink reflex is not useful as a postoperative test of facial nerve function in the operating room after anesthesia. In six patients, blink reflexes were still diminished 2-3 hours after cessation of anesthesia, at a time when patients were fully oriented and corneal and eyelid reflexes were clinically normal. This finding suggests that the blink reflex might be a sensitive test of subtle CNS dysfunction after inhalational anesthesia and potentially could serve as a useful objective indicator of recovery from anesthesia for outpatient surgery.

Adult↗
PubMed1992

[The indirect measurement of arterial pressure as a function of cuff width in patients in the immediate preoperative phase, the phase of entry into the operating room and in the postanesthesia phase].

The goal of this study was to compare blood pressure measures using two sizes of cuffs: one standard width (12 cm) and other with correct width that is 0.38 of arm circumference as recommended by American Heart Association. The comparisons were done among surgical patients in mediate perioperative phase, reception area of operation room and postoperative phase during the staying of the patient in the recovery room. The results demonstrated that the arterial blood pressure was hypoestimated by the use of the standard width cuff, reaching values up 30 mmHg in the systolic arterial pressure and 30 mmHg in the diastolic ones.

Adolescent↗
PubMed1994

Effect of flumazenil on recovery after midazolam and propofol sedation.

BACKGROUND: Flumazenil, a benzodiazepine antagonist, reverses midazolam-induced sedation and amnesia. We designed a double-blind study to evaluate the effects of flumazenil on patient outcome when flumazenil was used to reverse large or small doses of midazolam as part of standardized monitored anesthesia care. METHODS: Ninety-nine healthy consenting women undergoing breast biopsy procedures with local anesthesia were randomly assigned to one of four treatment groups: group 1, propofol-placebo (control); group 2, propofol-flumazenil; group 3, midazolam-placebo; or group 4, midazolam-flumazenil. All patients received intravenous midazolam 2 mg and intravenous fentanyl 50 micrograms, followed by an infusion of either propofol 25-150 micrograms.kg-1.min-1 or midazolam 0.5-4 micrograms.kg-1.min-1. At the end of the operation, patients were intravenously administered either 10 ml saline (groups 1 and 3) or flumazenil 1 mg in 10 ml saline (groups 2 and 4). Amnesia was assessed by determining recall of pictures shown before and after the procedure. Subjective feelings of sedation, anxiety, clumsiness, and fatigue were evaluated using 100-mm visual analogue scales preoperatively and at 30-min intervals in the recovery room. Cognitive function was assessed using the digit-symbol substitution test at similar intervals. Early recovery was evaluated by the ability of the patients to be transferred directly from the operating room to the step-down unit, as well as by times to ambulation and discharge. A standardized questionnaire and telephone interview were used to assess "resedation" and other postdischarge side effects. RESULTS: Flumazenil (1 mg) enhanced early recovery and picture recall after high-dose (group 4) but not low-dose (group 2) midazolam. Only 32% of patients in group 3 were transferred directly to the step-down unit compared with 85% in group 4 (P < 0.05). Flumazenil significantly improved visual analogue scale and digit-symbol substitution test scores at the 30- and 60-min testing intervals (P < 0.05). At the 90-min interval, there were no significant differences between groups 3 and 4. Compared with group 3 (84 +/- 22 min), patients in groups 1, 2, and 4 were ready for discharge significantly earlier (60 +/- 23, 65 +/- 21, and 67 +/- 27 min, respectively) (P < 0.05). However, 33% of the patients in group 4 reported resedation after discharge (vs. 0-8% in the other three study groups) (P < 0.05). CONCLUSIONS: Early recovery after breast biopsy procedures with midazolam sedation and flumazenil reversal is similar to recovery after propofol sedation. However, the beneficial effects of flumazenil were apparent only during the first 60 min after the procedure and resedation after discharge is an important consideration in the outpatient setting.

Adult↗
PubMed2003

The effect of cerebral monitoring on recovery after general anesthesia: a comparison of the auditory evoked potential and bispectral index devices with standard clinical practice.

UNLABELLED: The use of cerebral monitoring may improve the ability of anesthesiologists to titrate anesthetic drugs. However, there is controversy regarding the impact of the alleged anesthetic-sparing effects of cerebral monitoring on the recovery process and patient outcome. We designed this prospective double-blinded, sham-controlled study to evaluate the impact of intraoperative monitoring with the electroencephalogram bispectral index (BIS) or auditory evoked potential (AEP) device on the usage of desflurane and the time to discharge from the recovery room, as well as on patient satisfaction with their anesthetic experience and recovery. Ninety healthy patients undergoing laparoscopic general surgery procedures using a standardized anesthetic technique were randomly assigned to one of three monitoring groups: standard clinical practice (control), BIS-guided, or AEP-guided. Both the BIS and AEP monitors were connected to all patients before induction of general anesthesia. In the control group, the anesthesiologists were not permitted to observe the BIS or AEP index values during the intraoperative period. In the BIS-guided group, the volatile anesthetic was titrated to maintain a BIS value in the range of 45-55. In the AEP-guided group, the targeted AEP index range was 15-20. The BIS and AEP indices, as well as end-tidal desflurane concentration, were recorded at 3-5 min intervals. Recovery times to awakening, tracheal extubation, fast-track score >or=12, and postanesthesia care unit (PACU) discharge criteria were recorded at 1-10 min intervals. In addition, patient satisfaction with anesthesia and quality of recovery were evaluated on 100- and 18-point scales, respectively, at 24 h after surgery. The AEP- and BIS-guided groups were administered significantly smaller average end-tidal desflurane concentrations than the control group (3.8 +/- 0.9 and 3.9 +/- 0.6 versus 4.7 +/- 1.7, respectively) (P < 0.01). Although the emergence times to eye opening, tracheal extubation, and obeying commands were consistently shorter in the AEP and BIS groups (6 +/- 4 and 6 +/- 5 versus 8 +/- 8 min; 6 +/- 5 and 6 +/- 4 versus 11 +/- 10 min; and 8 +/- 4 and 7 +/- 4 versus 12 +/- 9 min, respectively), only the extubation times were significantly different from the control group (P < 0.05). More importantly, the length of the PACU stay was significantly shorter in both the AEP- and BIS-guided groups (79 +/- 43 and 80 +/- 47 versus 108 +/- 58 min, respectively) (P < 0.05). The patients' quality of recovery was also significantly higher in the two monitored groups (15 +/- 2 versus 13 +/- 3 in the control group, P < 0.05). We concluded that cerebral monitoring with either the BIS or AEP devices reduced the maintenance anesthetic (desflurane) requirement, resulting in a shorter length of stay in the PACU and improved quality of recovery after laparoscopic surgery. However, there were no significant outcome differences between the two cerebral monitored groups. IMPLICATIONS: Compared with standard monitoring practices, use of an auditory evoked potential or bispectral index monitor to titrate the volatile anesthetic led to a significant reduction in the anesthetic requirement. The anesthetic-sparing effect of cerebral monitoring resulted in a shorter postanesthesia care unit stay and improved quality of recovery from the patient's perspective.

Adult↗
PubMed1999

Small-dose ketamine enhances morphine-induced analgesia after outpatient surgery.

UNLABELLED: Small-dose ketamine may enhance the analgesic effect of opiates. We studied the effect of IV coadministration of small-dose ketamine 50-100 microg/kg with morphine 50 microg/kg on postoperative morphine requirements and pain in 140 patients undergoing outpatient surgery. Midazolam 1-2 mg was administered in the holding area. Anesthesia was induced with propofol 2-2.5 mg/kg and was maintained with desflurane in a nitrous oxide/oxygen mixture. Patients received morphine 50 microg/kg with placebo (Group 1, n = 35) or ketamine 50 microg/kg IV (Group 2, n = 35), 75 microg/kg IV (Group 3, n = 35), or 100 microg/kg IV (Group 4, n = 35) 15 min before the end of the operation. Pain and drowsiness were assessed using visual analog scales on arrival in the recovery room, then every 15 min until the time of discharge to phase 2 recovery (phase 1 recovery). Morphine consumption in Groups 3 and 4 was approximately 40% less than that in the control group (91+/-9 and 89+/-8 microg/kg vs. 145+/-9 microg/kg; P<0.05 for both). Pain scores in Groups 3 and 4 were approximately 35% less than those in the control group at all time periods (P<0.0001 for all). There was no significant group difference in drowsiness scores. Small-dose ketamine 75-100 microg/kg IV, enhanced morphine-induced analgesia after outpatient surgery. Simultaneous use of small doses of ketamine with morphine enhances the pain relief produced by morphine. IMPLICATIONS: Simultaneous use of small doses of ketamine with morphine enhances the pain relief produced by morphine.

Adult↗
PubMed1987

Brain ECF pH and central chemical control of ventilation during anoxia in turtles.

The role of changes in brain extracellular fluid [H+] in the control of breathing during anoxia was studied in unanesthetized turtles, Chrysemys scripta. Ventilation, [minute ventilation (VE), tidal volume (VT), and breathing frequency (f)], cerebral extracellular fluid (ECF) pH, and arterial blood gases were measured at 25 degrees C during a 30-min control period (room air), 30 min of anoxia (100% N2 breathing), and 60 min of recovery (room air). ECF pH was measured in the cerebral cortex with a glass microelectrode (1-2 micron tip diam). Large changes in ventilation, ECF [H+], and arterial blood gases were observed. The predominant ventilatory response was an increase in f with a slight increase in VT. A correlation was observed between ECF [H+] and f, which suggested that central chemoreceptor stimulation was involved in the ventilatory response.

Acid-Base Equilibrium↗
PubMed1988

Prevention of stroke during carotid endarterectomy.

From 1976 through 1985, 2857 carotid reconstructive procedures were performed on 2087 patients. Postoperative neurologic deficit occurred in 59 patients (2.1%). Thirty one patients (1.2%) suffered deficits that were permanent while 25 patients (0.9%) cleared to be discharged normal. In the last 5 years of the study, an aggressive approach was taken in cases where the patient was noted to have a postoperative neurologic change. It is routine to allow the patient to awaken in the operating room and to perform a simple neurologic examination prior to transport to the recovery room. If a neurologic change occurs during the postoperative period, immediate exploration is undertaken without preliminary testing. With this policy, 20 patients underwent exploration of the operated carotid artery and six of these patients recovered completely. To reduce the stroke rate from carotid endarterectomy (CE), technical errors must be kept to a minimum. Prevention of hypoperfusion with a shunt and careful mobilization of the artery to prevent microembolization should be practiced. Postoperative thrombosis can be decreased by the routine use of platelet antiaggregates and the avoidance of perioperative hypotension. Reperfusion of injury can be minimized by control of postoperative hypertension and proper preoperative selection of patients. Postoperative neurologic deficit following CE remains a relatively rare event and consequently sufficient experience in the treatment of this problem is difficult to acquire.

Blood Pressure↗
PubMed1983

Opsonic fibronectin deficiency in patients with intra-abdominal infection.

The reticuloendothelial system provides host defense functions by the intravascular phagocytosis of bacteria and nonbacterial particulates. Fibronectin is opsonic for reticuloendothelial phagocytosis. Plasma fibronectin was measured before and after operation in patients with intra-abdominal infection. Preoperatively opsonic fibronectin was reduced by 39% of normal control levels in 16 patients with intra-abdominal infection. There was an even greater reduction of opsonic fibronectin after operation that was first observed in the recovery room. This deficiency persisted for the first 4 days with a tendency toward recovery of normal circulating levels by the fifth postoperative day. In contrast, patients who underwent elective major abdominal operation without infection manifested a transient opsonic fibronectin deficiency with recovery by the second and third postoperative days. Eight of 16 patients with intra-abdominal infection developed multiple organ failure. The opsonic fibronectin levels in those patients were lower than the levels in eight patients who did not develop multiple organ failure. Furthermore, there was no tendency toward recovery of normal circulating opsonic fibronectin in those patients. On all days when multiple organ failure occurred there was a marked deficiency of circulating opsonic fibronectin. We conclude that transient opsonic fibronectin deficiency occurs after major elective abdominal operation. Patients with intra-abdominal infection manifest opsonic fibronectin deficiency before operation, and further depletion of opsonic fibronectin occurs after operation. Postoperative multiple organ failure occurs only in association with severe opsonic fibronectin deficiency.

Abdomen↗
PubMed1993

[A comparative study of recovery following maintenance of anesthesia with propofol or isoflurane. An attempt to synthesize current data].

Quality of recovery is a means to improve anaesthetic safety during postoperative time, in post-anaesthesia recovery room and especially when the patient returns to his unity. The comparison of recovery after maintenance of anaesthesia with propofol or isoflurane shows that, for 50 to 60 min surgical procedures, results are significantly better with isoflurane. Review of literature shows that, for less than 30 min operations, propofol seems to give best recovery. For more than 30 min operations, isoflurane enables better quality recovery.

Adolescent↗
PubMed1997

Heat conservation vs convective warming in adults undergoing elective surgery.

PURPOSE: To determine the relative efficacy of heat conservation and convective warming in maintaining perioperative normothermia, (central temperature > or = 36 degrees C). METHODS: Thirty-seven patients undergoing elective gynaecological, orthopaedic, or general surgery scheduled to last two hours were prospectively studied. Patients were randomized to one of two groups. Group 1 patients received heat conservation with reflective blankets (Thermadrape, Vital Signs, Inc., Totowa, NJ) applied preoperatively and warmed i.v. fluids (Hotline SIMS Level I Technologies, Inc, Rockland, MA), Group 2 patients received convective warming (BairHugger, Augustine Medical Inc., Eden Prairie, MN) after induction of anaesthesia and i.v. fluids at room temperature. All patients received general anaesthesia with isoflurane. Tympanic membrane and forearm-fingertip skin temperature gradients were measured perioperatively at 15 min intervals. RESULTS: Central temperature decreased after induction to a minimum level of 35.9 +/- 0.1 degrees C in group 1 and 36.0 +/- 0.1 degrees C in group 2 and then increased towards pre-induction values in group 2, and were higher (P < 0.05) than in group 1: 95% group 2 patients had central temperature > or = 36.0 degrees C at the end of surgery (vs 69% of group 1, P < 0.05). During the first 30 min in PACU, central temperatures were higher in group 1 than in group 2 (36.8 +/- 0.1 degrees C vs 36.2 +/- 0.2 degrees C, P < 0.05). After 60 min, central temperatures were similar (36.8 degrees C). The incidence of shivering and degree of peripheral cutaneous vasoconstriction were also similar. CONCLUSION: Patients receiving convective warming were more likely to leave the operating room normothermic, and had higher central temperatures during the first 30 min in the recovery room. The intergroup temperature differences were small, and by 60 min, had disappeared.

Adult↗