Society Of Anaesthesia And Intensive Care Research Articles

Pulse contour techniques for perioperative hemodynamic monitoring: A nationwide carbon footprint and cost estimation

BackgroundThe question of environmentally sustainable perioperative medicine represents a new challenge in an era of cost constraints and climate crisis. The French Society of Anaesthesia and Intensive Care (SFAR) recommends stroke volume optimization in high-risk surgical patients. Pulse contour techniques have become increasingly popular for stroke volume monitoring during surgery. Some require the use of specific disposable pressure transducers (DPTs), whereas others can be used with standard DPTs. ObjectiveQuantify and compare the carbon footprint and cost of pulse contour techniques using specific and standard DPTs on a yearly basis and at a national level. MethodsWe estimated the number of high-risk surgical patients monitored every year in France with a pulse contour technique, and the plastic waste, carbon footprint and cost associated with the use of specific and standard DPTs. Main findingsWhen compared to pulse contour techniques working with a standard DPT, techniques requiring a specific DPT are responsible for an increase in carbon dioxide emission estimated at 65–83 tons/yr and for additional hospital cost estimated at €67 million/yr. If, as recommended by the SFAR, all high-risk surgical patients were monitored, the difference would reach 179–227 tons/yr for the environmental impact and €187 million/yr for the economic impact. ConclusionFrom an environmental and economic standpoint, pulse contour techniques working with standard DPTs should be recommended for the perioperative hemodynamic monitoring of high-risk surgical patients.

Women in Anaesthesia and Intensive Care Medicine in France: Are we making any progress?

IntroductionGender imbalance in medicine is a topic of increasing interest. Gender matters, as there is increasing evidence that a gender diverse medical workforce translates into improved patient outcomes. The gender distribution in France among the Anaesthetists-Intensive Care (AIC) physicians has never been considered. MethodsGender distribution is described during the last two decades in France among the whole population of AIC physicians according to their age, professional activity, leading and academic position. ResultsThe proportion of female AIC physicians remained stable from 1999 to 2018, between 35 and 38%. Only 40% of residents choosing this specialty in 2018 were female. Female AIC physicians were under-represented in key medico-political and academic positions: in 2018, 0.7% of the 605 presidents of medical commissions from public hospitals and none of the medical university deans were female AIC physicians; 9% of AIC full Professors were female. In the French Society of Anaesthesia and Intensive Care (SFAR), 42% of the members of the Scientific Committee of our Society are women. ConclusionsA gender imbalance is apparent in French AIC Medicine and worsens as physicians progress through their academic or leadership pathways. The French Society of Anaesthesia and Intensive Care campaigns for proportional representation at all levels of leadership, which translates into more gender equality in the committees of the society, including the Scientific Committee. A major policy shift is urgently required to support women, to tend toward gender parity to increase the performance of the French AIC workforce.

Preliminary pragmatic lessons from the SARS-CoV-2 pandemic in France

The first wave of the SARS-CoV-2 pandemic required an unprecedented and historic increase in critical care capacity on a global scale in France. Authors and members from the ACUTE and REANIMATION committees of the French Society of Anaesthesia and Intensive Care (SFAR) wished to share experience and insights gained during the first weeks of this pandemic. These were summarised following the World Health Organization Response Checklist and detailed according to the subsequent subheadings: 1. Command and Control, 2. Communication, 3. Safety and Security, 4. Triage, 5. Surge Capacity, 6. Continuity of essential services, 7. Human resources, 8. Logistics and supply management, 9. Training/Preparation, 10. Psychological comfort for patients and next of kin, 11. Learning and 12. Post disaster recovery. These experience-based recommendations, consensual across all members from both committees of our national society, establish a practical framework for medical teams, either spared by the first wave of severe COVID patients or preparing for the second one.

Opioids and nonopioids for postoperative pain control in patients with chronic kidney disease.

To evaluate postoperative pain management (POPM) practices by anesthesiologists caring for patients with chronic kidney disease (CKD). Prospective one-time survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR). A self-administered online questionnaire was distributed to members of SFAR nationally. Three hundred seven SFAR members participated in the study. Close-ended questions concerned: standard test used to assess renal function, analgesic agent selection and dose adjustment based on the CKD functional stage, and the availability of standard operating procedures. The primary end-point was to identify the most frequently prescribed analgesics in case of CKD, variations in practice based on different stages of CKD, and drug dosing adjustments. The secondary end-point was to identify the most commonly used tests to evaluate kidney function. The most commonly used postoperative analgesics were paracetamol (acetaminophen) and morphine. The most commonly used opioid was morphine, relative to oxycodone and sufentanil. Modification of diet in renal disease (MDRD) and Cockcroft equations were used by 39 and 40 percent of anesthesiologists, respectively, to measure kidney function. Six percent of anesthesiologists declared following standard operating procedures for POPM in patients with CKD. There is considerable variability in POPM practices for patients with all stages of CKD. Morphine is favored even in end-stage renal disease. Departments of anesthesiology are insufficiently involved in drafting standard operating procedures.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0189-6) contains supplementary material, which is available to authorized users.

Experts' recommendations for the management of adult patients with cardiogenic shock.

Unlike for septic shock, there are no specific international recommendations regarding the management of cardiogenic shock (CS) in critically ill patients. We present herein recommendations for the management of cardiogenic shock in adults, developed with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system by an expert group of the French-Language Society of Intensive Care (Société de Réanimation de Langue Française (SRLF)), with the participation the French Society of Anesthesia and Intensive Care (SFAR), the French Cardiology Society (SFC), the French Emergency Medicine Society (SFMU), and the French Society of Thoracic and Cardiovascular Surgery (SFCTCV). The recommendations cover 15 fields of application such as: epidemiology, myocardial infarction, monitoring, vasoactive drugs, prehospital care, cardiac arrest, mechanical assistance, general treatments, cardiac surgery, poisoning, cardiogenic shock complicating end-stage cardiac failure, post-shock treatment, various etiologies, and medical care pathway. The experts highlight the fact that CS is a rare disease, the management of which requires a multidisciplinary technical platform as well as specialized and experienced medical teams. In particular, each expert center must be able to provide, at the same site, skills in a variety of disciplines, including medical and interventional cardiology, anesthesia, thoracic and vascular surgery, intensive care, cardiac assistance, radiology including for interventional vascular procedures, and a circulatory support mobile unit.

Prise en charge des dermohypodermites bactériennes nécrosantes et fasciites nécrosantes en réanimation : résultats d’une enquête de pratique francophone

ObjectivesNecrotizing fasciitis (NF) are rare and severe soft tissue infections associated with a high mortality rate. In order to assess the management of NF in French-speaking intensive care units (ICUs), we conducted a survey endorsed by the French Society of Anesthesia and Intensive Care (SFAR). Study designOnline self-administered survey. MethodsA link to an online survey was sent by email to 4620 anesthesiologists and/or intensivists and was available online from January to February 2014. ResultsOne hundred and seventy-five physicians (3.8%) who worked in 135 ICUs filled out the online survey. Among respondents, 42% reported having managed up to two patients with NF during the previous year; 59% and 72% of respondents reported not having a surgical and a medical specialist consultant, respectively. A delayed access to the operating room (OR) of more than 6hours was reported in 31% of cases and access to the OR was reported not to be routinely considered as a priority in 13% of cases. Only 17% of respondents reported that time to transfer to the OR was never a cause for delayed surgery. The main causes for delayed surgery were: delayed diagnosis (45%), delayed validation of surgical intervention (37%), and difficulty of access to the OR (8%). Finally, 83% of respondents estimated that creating dedicated multidisciplinary teams for managing NFs could lead to improving outcomes. ConclusionThis survey illustrates the heterogeneous management of NF in French-speaking ICUs and points out several logistical aspects that should be improved to reduce the time to the first surgical debridement.

Antibioprophylaxie pour césarienne : modification des pratiques et administration avant incision, enquête de faisabilité auprès des pédiatres du réseau de santé périnatale d’Auvergne (RSPA)

ObjectiveTo describe the knowledge of paediatricians regarding the practice of antimicrobial prophylaxis for caesarean section in reference to the Consensus Conference of the French Society of Anesthesia and Intensive Care (SFAR) and assess the feasibility of a change in attitude (injection of the antibiotic prior to incision) among paediatricians Perinatal Health Network of Auvergne (RSPA) working in maternity. Study designCross sectional study by survey. MethodsFirst questionnaire was sent to 46 RSPA paediatricians working in maternity. Almost one-third of paediatricians who returned the questionnaire said they were not concerned. A second questionnaire was developed with two paediatricians of the CHU and sent to the same 46 paediatricians. The statistical part involved percentages. ResultsResponse rates were respectively 61% and 67%. For the first questionnaire, only 25% of the paediatricians knew the antibiotic and the time for injection. For the second questionnaire, 87% were in favour of an administration before incision and 42% thought it will not affect the care of the newborn. For 35% of respondents, it could lead to a change in the duration of antibiotic therapy in cases of perinatal infection and for 13% only a delay in the implementation of antibiotic therapy in children. ConclusionThe RSPA paediatricians did not know the practices of antibiotic prophylaxis for caesarean section. However, they did not appear opposed to an administration before cord clamping as it would not delay the implementation of any antibiotics in the newborn.

Demography of French anaesthesiologists. Results of a national survey by the French College of Anaesthesiologists (CFAR) and the French National Society of Anaesthesia and Intensive Care (SFAR), supported by the National Institute for Demographic Studies (INED).

The perception of a looming manpower shortage led the French College of Anaesthesiologists (CFAR) and the French Society of Anaesthesia and Intensive Care (SFAR), with assistance from the National Institute for Demographic Studies (INED), to conduct a national survey of French anaesthesiologists in order to determine precise physician characteristics data, analyse professional practices and project future service provision. The survey was based on self-administered individual questionnaires, approved by the National Committee on Informatics and Freedom (CNIL). The survey was carried out at the end of 1998 among 1484 hospitals (590 public and 894 private), under the supervision of local referees and regional co-ordinators. Of 9741 anaesthesiologists' posts, 5694 (58%) are in public hospitals, 3569 (37%) in private practice and 478 (5%) in private hospitals within the National Health Service, i.e. the participant au service public hospitalier (PSPH). Complex validation of the results was necessary to account for the missing responses and multiple sites of activity. The survey identified 8876 specialists practising anaesthesia and intensive care in France at the beginning of 1999, including 216 in French overseas territories. This figure is consistent with that published by the Medical Council (Ordre des Médecins) on 1 January 1999, identifying 8950 anaesthesiologists in France, including 234 in the overseas territories. Annual growth in the anaesthesiologist population has fallen from 9% pre-1989 to 0% in 1999. Male anaesthesiologists outnumber females (35.7%). The average age has risen from 42.8 yr in 1989 to 45.9yr in 1999. The age distribution of anaesthesiologists has become bell shaped, reflecting reduced numbers of younger practitioners. There are currently 14.75 anaesthesiologists per 100 000 people (compared to 12.9 in 1989), a figure slightly above the European average, but there is considerable geographical inequality between the north and south of France, with increased concentrations in large cities that contain university hospitals. Future service provision must take account of falling numbers of new anaesthesiologists and an increase in retirements, but must also include changes in working practices, such as the European Working Time Directive. If anaesthesia manpower shortages are to be avoided, there must be a restructuring of the work-place, a redefinition of tasks and improved management of working time.

Demography of French anaesthesiologists. Results of a national survey by the French College of Anaesthesiologists (CFAR) and the French National Society of Anaesthesia and Intensive Care (SFAR), supported by the National Institute for Demographic Studies (INED)

Demography of French anaesthesiologists. Results of a national survey by the French College of Anaesthesiologists (CFAR) and the French National Society of Anaesthesia and Intensive Care (SFAR), supported by the National Institute for Demographic Studies (INED)

Évaluation de 44 filtres échangeurs de chaleur et d’humidité. Que choisir ?

Objectives. – If the use of heat and moisture exchange filter (HMEF) in anaesthesia is recommended by the French Society of Anaesthesia and Intensive Care (SFAR), the criteria’s choice are not clearly defined. Many HMEF are proposed by manufacturers which technical characteristics are different. Study design. – The aim of this study was to evaluate the HMEF using items of the American Association of Respiratory Care (AARC) and technical dossiers. Methods. – All manufactures producing filters have been contacted to give their technical dossiers. Forty-eight filters have been analyzed (13 mechanical filters, 31 electrostatic filters). Each item has been scaled 0, 5 or 10. The final result was on 10. Results. – Seventeen filters had a note superior to 5. There were 8 mechanical filters and 9 electrostatic filters. The difference between the filters was the size of the micro-organisms tested and the duration of the test. Some filters were not tested by independent laboratories ( N = 8). There were differences between the commercial documentation and on Internet and the technical dossiers ( N = 12). Discussion. – We noted the good quality of the filters particularly concerning criters recommended by the Sfar (filter medium, filtration efficiency, microbial challenge number and duration of the test). The electrostatic filters recently used in anaesthesia have high performance concerning filtration efficiency. To supprime the moisture output criteria did not change the results. Conclusion. – Criteria’s used by manufactures to evaluate there filters are not always precised or too restrictive. The technical tests, the international norms, the certificates of validation, the ergonomic qualities and the definition of our needs are the main elements of choice of a filter.

A study of practice patterns of albumin administration in surgical patients by anesthetists

The establishment of guidelines has to take into account the current practice patterns. For the preparation of the consensus conference organized by the French Society of Anesthesia and intensive care (SFAR) on the prescription of albumin, an interview with a questionnaire was undertaken in order to assess the practice patterns of anaesthetists during the perioperative period. A group of 498 anaesthetists were interviewed during a congress. Two out of three prescribe albumin. In case of haemorrhage, the decision to administer albumin depends on the limits for using other colloids (for 65% of the responders), the amount of blood loss (46%) and albuminaemia (for only 26%). In other cases, albumin is mainly administered in the burn patient and for recurring ascite; albuminaemia is a decision criterion for one anesthetist out of two. About 25% of them use a 20% concentration, another 25% of them a 4% concentration and the remaining 50% use both concentrations. Adverse effects have been seen in less than 5% of the responders. These data have been presented at the consensus conference and can also be used for the assessment of the impact of the guidelines after their publication.

Arguments en faveur de l'équipement de l'appareil d'anesthésie d'une bouteille d'oxygène de secours

In France, the presence of an emergency oxygen cylinder as part of every the anaesthetic machine is not made compulsory by an official regulation. This article provides arguments in favour of such a presence, as recommended by the French Society of Anaesthesia and Intensive care (SFAR).

Utilisation du Diprivan ® pour les endoscopies digestives

After evaluation of the patient's clinical condition and appropriate premedication is seems reasonable to suggest for: 1. Endoscopic procedures involving the gastro-intestinal tract: slow, titrated induction, using 0.5 to 1 mg.kg-1 of propofol, until the required level of sedation has been achieved; this may or not be preceded by the injection of a low dose of midazolam (0.02 to 0.03 mg.kg-1) or of alfentanil (5 micrograms.kg-1); maintenance is achieved by bolus injections of 20 mg (up to 0.5 mg.kg-1); maintenance of spontaneous ventilation, with oxygen administration is the rule; SpO2 is monitored routinely; anaesthesia has to be performed according to the recommendations of the French Society of Anaesthesia and Intensive Care (SFAR) and the anaesthetist must be prepared to manage any incident during the endoscopy and the recovery period. 2. Procedures involving the biliary tract and the oesophagus, which require deeper anaesthesia: induction should again be titrated using a very slow infusion, with doses ranging from 0.9 to 2.2 mg.kg-1); the maintenance requires a continuous infusion, doses ranging from 4 to 6 mg.kg-1.h-1 when propofol is administered alone and from 4 to 12 mg.kg-1.h-1 when combined with an opioid; continuous oxygenation is necessary using a nasal airway; the need for intubation depends on the type of procedure and the status of the patient; the same monitoring devices and similar safety measures are required during and after procedure as for any anaesthetic or sedation, especially when it is performed in day-case patients or outside the operating theatre.