Critical appraisal of organ procurement under Maastricht 3 condition

The ethics committee of the French Society of Anesthesia and Intensive Care (Sfar) has been requested by the French Biomedical Agency to consider the issue of organ donation in patients after the decision to withdraw life-supportive therapies has been taken. This type of organ donation is performed in the USA, Canada, the United Kingdom, the Netherlands and Belgium. The three former countries have published recommendations formalizing procedures and operations. The French Society of Anesthesia and Intensive Care (Société française d'anesthésie et de reanimation [Sfar]) ethics committee has considered this issue and envisioned the different aspects of the whole process. Consequently, it sounded a note of caution regarding the applicability of this type of organ procurement in unselected patients following a decision to withdraw life-supportive therapies. According to French regulations concerning organ procurement in brain-dead patients, the committee stresses the need to restrict this specific way of procurement to severely brain-injured patients, once confirmatory investigations predicting a catastrophic prognosis have been performed. This suggests that the nature of the confirmatory investigation required should be formalized by the French Biomedical Agency on behalf of the French parliamentarians, which should help preserve population trust regarding organ procurement and provide a framework for medical decision. This text has been endorsed by the Sfar.

[Citation errors: Uplavici (for Hlava) and William the Silent (for Jules Verne and Mignet)]

A certain 'O Uplavici' was cited for more than fifty years, although he had never existed. This error probably came from a misinterpretation of the Czech language, in which the real author's name--Hlava--can mean 'Title'. It was finally recognized, which was not the case for the author of the sentence: 'I have no need of hope to take action, nor of success to persevere', it is still regularly attributed in France to William I, Prince of Orange, called the Silent. It is a mistake, and no serious reference certifies that an historical figure would have pronounced this sentence. It was written by the historian Mignet in 1841, to describe the character of William III, Prince of Orange and King of England. It was then used in 1875 by Jules Verne, to describe a character in 'The Mysterious Island'.

Mortality related to anaesthesia in France: analysis of deaths related to airway complications

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

[Autopsy of a common error: the introduction of curare in Europe by W. Raleigh]

One of the most erroneous and repeated assertion in the history of pharmacology for anaesthetists is to say that "the curare was introduced in Europe by Sir Walter Raleigh under the name of ourari". On the contrary, the names to be reminded are: Lawrence Keymis for the first citation of the word ourari, José Gumilla for the word curare and the description of its effects, Charles-Marie de La Condamine for the import of the first known samples. The mistake was initiated by Alexander von Humboldt and developed by the physiologist Münter, a student of Johannes Müller, quoted by Claude Bernard. The repetition of this error was facilitated by the world diffusion of Claude Bernard's work.

[Changes in transfusion practice for surgery]

The context of transfusion has changed in recent years. Some data could lead to an increased demand: the risk of viral transmission has significantly decreased; a national survey has revealed that the mortality related to an insufficient or delayed transfusion was higher to the side effects of the transfusion itself. Some other data could decrease the demand: the preoperative use of EPO is now easier; the intraoperative use of antifibrinolytic has been shown to be efficient. The number of allogenic red blood cells units (RBCs) transfused each year in France regularly increases, while the transfusion of predeposited autologous blood is in sharp decline. However, in hospitals still using but reducing this technique, the consumption of allogenic RBCs does not increase and the transfusion of any blood (allogenic and/or autologous) decreases. The strategy is based on preoperative evaluation of usual blood loss and tolerable blood loss by accepting a reasonable risk of allogenic blood transfusion. Advances in public health seem to be found above all in the analysis of system failures.

Adaptability of protein A-immunoadsorption allows temporary reduction of anti-VIII antibodies and realisation of high-risk haemorrhagic surgery

We report the successful treatment by protein A-immunoadsorption (IA) of an hemophilic man with anti-F VIII antibodies (Abs) who needed high-risk bleeding surgery. This patient had developed high levels of anti-F VIII Abs preventing substitution by clotting factor and preventing high-risk bleeding surgery. Because of rebound in Abs levels or complications, IA procedures were modified several times leading to appropriate decrease of anti-F VIII inhibitor Abs allowing bilateral knees surgery. IA procedure is enough adaptable to be modified to prevent complications. Collaboration between clinical, biological, apheresis and surgical teams implied has permitted surgery and prevented life-threatening bleeding complications.

Cost analysis applied to postoperative analgesia regimens: a comparison between parecoxib and propacetamol

BACKGROUND

Postoperative pain management represents a significant part of perioperative costs. Non-opioid analgesics are often used in combination with opiates to improve pain relief and reduce opioid-related side effects.

OBJECTIVE

To assess the costs and cost efficacy of intravenous (i.v.) parecoxib versus i.v. propacetamol in postoperative pain.

METHODS

A prospective, randomised, double-blind, clinical evaluation was performed to compare the efficacy of a single bolus injection of 40 mg parecoxib and 2 g propacetamol, administered twice within 12 h following surgical repair of inguinal hernia. Resources for each arm of treatment were collected, and total costs were determined, including costs of drug acquisition, devices and labour for preparation of the two analgesic drugs. Cost-efficacy analysis was performed as the cost to achieve complete satisfaction with analgesia. Incremental cost efficacy was determined as the ratio between the differential costs and the differential patient satisfaction. The analysis was performed from an institutional perspective over a 12 h time frame.

RESULTS

A total of 182 patients was evaluated. Pain at rest and morphine consumption were observed to be reduced in the parecoxib group. The percentages of patients totally satisfied with their pain management 12 h after surgery were 87% in the parecoxib-treated group and 70% in the propacetamol-treated group (P < 0.01). The average cost per patient was higher in the parecoxib group, 6.65 euros vs 5.28 euros in the propacetamol group). Cost per patient satisfied was calculated at a mean value of 7.64 euros for parecoxib and 7.54 euros for propacetamol. Incremental cost per additional patient satisfied was 8.02 euros in the parecoxib-treated group when preparation costs were included. Sensitivity analysis (+/-15%), including a bootstrap method applied to costs and efficacy, did not modify these conclusions.

CONCLUSION

Parecoxib exhibits higher cost and greater patient satisfaction than does propacetamol. From a cost-efficacy approach, incremental cost per additional patient satisfied for parecoxib treatment must be analysed in light of overall perioperative pharmaceutical cost.

Acute desflurane or sevoflurane exposure on a previously stabilized atracurium-induced neuromuscular block

BACKGROUND AND OBJECTIVE

The aim of this prospective study was to compare the effect of the administration of desflurane or sevoflurane to a fixed neuromuscular block.

METHODS

After written consent, 12 patients were anaesthetized with propofol and sufentanil. Atracurium was administered via a continuous infusion in order to obtain 85% twitch depression of the control value assessed by repeated accelerometric stimulation at the adductor pollicis. Once stabilized over the course of 30 min, propofol was discontinued and either desflurane (n = 6) or sevoflurane (n = 6) was delivered at 1 MAC in a mixture of 50% O(2) in air. Study parameters were the magnitude and the time of twitch height variations. Results are presented in mean +/- SD.

RESULT

Exposure to halogenated agents led to a significant reduction in twitch height with similar magnitude between the two agents. However, interaction with desflurane showed an initial and transient rise (35 +/- 22%) in twitch height before subsequent depression occurred. The time to reach 50% of the signal depression in the desflurane group was significantly delayed (25 +/- 7 vs. 11 +/- 4 min in the sevoflurane group; P < 0.01).

CONCLUSIONS

On a stable neuromuscular block elicited by continuous infusion of atracurium, the abrupt administration of desflurane or sevoflurane reduces the accelerometric responses of the adductor pollicis in a similar way. This potentiating effect is produced faster after sevoflurane than after desflurane. With desflurane, a biphasic effect (of a transient and moderate increase followed by depression of the signal) was recorded.

Impact of Choice of Treatment for Bleeding Episodes on Inhibitor Outcome in Patients With Mild/Moderate Hemophilia A and Inhibitors

Patients with mild/moderate hemophilia A (MHA) may develop inhibitors to factor VIII (FVIII). In this condition, FVIII clotting activity (FVIII:C) baseline levels may remain stable for some patients, but may be reduced to less than 0.01 U/mL for others. Several risk factors for the development of inhibitors in MHA have been proposed. Genetic factors, such as mutations in the FVIII gene, may play a central role; however, other influences, such as intensive treatment with FVIII products, may also be important. Optimal treatment regimens have yet to be determined, not only for the eradication of inhibitors, but also for the management or surgical prophylaxis of hemorrhages associated with this condition. Several treatment options for the control of bleeding in patients with MHA and inhibitors (MHAI) are currently available, and the choice of therapeutic strategy should be given careful consideration; some treatments may produce an anamnestic response, thus delaying the return to FVIII:C baseline levels and adversely affecting the duration of the severe bleeding phenotype. To increase our knowledge of MHAI, a retrospective collection of data is currently being performed among hemophilia centers in France and Belgium. Based on five examples of patients with MHAI collated from preliminary study data, we illustrate the impact on inhibitor outcome of the therapeutic choices used to treat bleeding episodes in these patients.

Major surgery in a severe haemophilia A patient with high titre inhibitor: use of the thrombin generation test in the therapeutic decision

Summary. In haemophilia patients with inhibitor, elective orthopaedic surgery is usually performed under recombinant activated factor VII (rFVIIa). We report here the case of a severe haemophilia A patient with a high inhibitor who needed a bilateral total knee arthroplasty. Recombinant FVIIa was previously shown to be ineffective for the treatment of muscle and joint bleedings, and he had a history of excessive postoperative bleeding under activated prothrombin complex concentrate (APCC). Thrombin generation test (TGT) was used to assess the efficacy of Factor Eight Inhibitor Bypassing Activity (FEIBA). Insufficient correction of thrombin-generating capacity was observed after administration of 75 U kg(-1) FEIBA. In a multidisciplinary environment, a bilateral total knee arthroplasty was performed using a protocol combining immunoadsorption of inhibitors preoperatively associated with FVIII replacement during a first phase followed by FEIBA when the inhibitor reappeared. To our knowledge this is the first direct application of TGT in the management of haemophilia patients with inhibitor, which indicated that a sequential use of immunoadsorption, FVIII and FEIBA was the most appropriate treatment to perform this major elective surgery. This case demonstrates that this combined protocol can be safely used to cover major surgery in inhibitor patients. In addition, it also suggests that TGT may have a major contribution in the decision-making process of the most adapted therapy for the treatment of such high-risk patients.

A Randomized, Double-Blind Comparison Between Parecoxib Sodium and Propacetamol for Parenteral Postoperative Analgesia After Inguinal Hernia Repair in Adult Patients

The newly injectable cyclooxygenase-2 selective nonsteroidal antiinflammatory drug, parecoxib, has never been compared with propacetamol, a parenteral formulation of acetaminophen. In this prospective, randomized, double-blind, double-dummy study, we randomly assigned 182 patients scheduled for initial inguinal hernia repair under general anesthesia to receive a single injection of 40 mg parecoxib or 2 injections of 2 g propacetamol within the first 12 h after surgery. The study variables were morphine consumption, pain at rest and while coughing, and patient satisfaction throughout the first 12 h postoperatively. For statistical analysis, we used the Student's t-test, chi(2), and covariance analysis. Total morphine consumption did not differ between the two groups. Pain was less intense in the parecoxib group at rest (P = 0.035) but did not differ for pain while coughing. The incidence of side effects was similar. Significantly more patients in the parecoxib group rated their pain management as good or excellent (87% versus 70% in the propacetamol group, P = 0.001). Within the first 12 h after inguinal hernia repair in adult patients, a single injection of parecoxib 40 mg compares favorably with 2 injections of propacetamol 2 g.

Reducing the risk of anaphylaxis during anaesthesia: guidelines for clinical practice

These guidelines represent a consensus of experts in the field of immediate hypersensitivity reactions occurring during anaesthesia. They were based on international science, and implemented in France under the auspices of the French Society for Anaesthesia and Intensive Care (SFAR: Société Française d'Anesthésie et de Reanimation). Their aim was to provide the most valid, widely accepted, effective and easily teachable guidelines that current knowledge, research and experience can provide. This paper presents the main extracts of these recommendations with the most relevant clinical implications.

[Factors associated with laparoscopic approach for cholecystectomy, appendicectomy and inguinal herniorraphy in France]

OBJECTIVE

To determine on a national level the factors associated with the use of laparoscopy for digestive surgery.

STUDY DESIGN

Nation wide study using a large representative sample (3 days of anaesthesia in France).

METHODS

Univariate followed by multivariate analyses of data gathered in 1996 during the survey led by the French Society of Anaesthesia and Intensive care ("SFAR") including 2847 surgical procedures for cholecystectomy, appendicectomy or inguinal herniorraphy.

RESULTS

Independent factors associated with the use of laparoscopy were: for cholecystectomy: age (less frequent when > or =71 years: adjusted Odds ratio [AOR] 0.4), sex (more frequent in female: AOR 1.7), ASA physical status (less frequent when > or =3: AOR 0.5), private hospital (AOR 2.0), procedure scheduled at least the night before (AOR 2.1), and use of closed circuit general anaesthesia (AOR 1.6); for appendectomy: age >15 years (AOR 1.9-2.2), female (AOR 2.1), private hospital (AOR 2.7), scheduled procedure (AOR 2.1), prolonged procedure (AOR 8.4), endotracheal intubation (AOR 16.7), and closed circuit (AOR 2.7); for inguinal herniorraphy: ASA physical status (less frequent when > or =3: AOR 0.4), private hospital (AOR 3.4), prolonged procedure (AOR 5.6), and endotracheal intubation (AOR 21.6). Association with a closed circuit was confirmed for general anaesthesia using a volatile agent (AOR 1.5). Overall, ambulatory surgery was rarely performed and used only for open procedures. Regional anaesthesia was used only for inguinal open herniorraphy.

CONCLUSION

These data obtained from a large national survey confirmed the higher frequency of laparoscopy in middle aged patients, female (except for inguinal herniorraphy), without important comorbidity, in private hospitals. Laparoscopy was associated with prolonged procedures and with a change in the anaesthetic technique for appendicectomy and inguinal herniorraphy: tracheal intubation was almost constantly used. Whatever the procedure, closed circuit anaesthesia was more frequently used when surgery was performed under laparoscopy, reflecting newer equipment of the hospital, private or public.