François Clergue

French survey of anesthesia in 1996.

BACKGROUND To identify the growth in the number of anesthetic procedures since 1980 and the changes in the practice of anesthesia, the present survey was designed to collect and analyze the anesthetic activity performed in France in 1996, from a representative sample collected in all French hospitals and clinics. METHODS This study, initiated by the French Society of Anesthesia and Intensive Care, collected information that included the characteristics of patients (age, sex, American Society of Anesthesiologists status), the techniques of anesthesia, and the nature of the procedure for which anesthesia was required. All French private, public, and military hospitals were asked to participate in the survey. In each hospital in the country, all anesthetic procedures were documented and collected during 3 consecutive days, chosen at random during a 12-month period, to obtain a representative sample of the annual activity. All data were analyzed at the INSERM (National Institute of Health and MEDICAL RESEARCH: At the conclusion of the study, 5% of hospitals were randomly assigned to be audited to check for missing data and errors. The rate of anesthetic activity was calculated as the ratio between the annual number of anesthetic procedures and the number of the general population in the same age group. RESULTS The participation rate of hospitals was 98%. The analysis of the 62,415 collected questionnaires allowed extrapolation of the anesthetic activity to 7,937,000 anesthetic procedures (95% confidence interval, +/- 387,000) performed in France in 1996. Thus, the annual rate of anesthetic procedures was 13.5 per 100 population, varying between 5.4 per 100 in girls aged 5-14 yr and 30.2 per 100 in men aged 75-84 yr. Surgery was involved in 71% of anesthesia cases. Regional anesthesia alone was performed in 20% of all surgical cases and was combined with general anesthesia in 3% of additional cases. Anesthesia for obstetric procedures represented 9% of all cases. Seventy-six percent of all anesthetic procedures started between 12:00 A.M. and 7:00 A.M. were related to obstetric activities. CONCLUSION In comparison with a previous study, the present survey shows that the number of anesthetic procedures has increased by 120% since 1980, and the rate of anesthetic procedures increased from 6.6 to 13.5 per 100 population, the major changes being observed in patients aged > or = 75 yr and in those with an American Society of Anesthesiologists physical status of 3. In the same time period, the number of regional anesthetic procedures increased 14-fold. In obstetrics, the practice of epidural analgesia extended from 1.5% to 51% of all deliveries of the country.

Gefitinib, an EGFR inhibitor, prevents hepatocellular carcinoma development in the rat liver with cirrhosis†

Epidermal growth factor receptor (EGFR) binds transforming growth factor α (TGF‐α) which is mitogenic for hepatocytes. Diverse lines of evidence suggest that activation of the TGF‐α /EGFR pathway contributes to hepatocellular carcinoma (HCC) formation. Herein, we developed an experimental model of cirrhosis giving rise to HCC and tested the antitumoral effect of gefitinib, a selective EGFR tyrosine kinase inhibitor, in this model. Rats received weekly intraperitoneal injections of diethylnitrosamine (DEN) followed by a 2‐week wash‐out period that caused cirrhosis in 14 weeks and multifocal HCC in 18 weeks. Hepatocyte proliferation was increased in diseased tissue at 14 weeks compared with control liver and at even higher levels in HCC nodules compared with surrounding diseased tissues at 18 weeks. Increased proliferation was paralleled by upregulation of TGF‐α messenger RNA expression. A group of DEN‐treated rats received daily intraperitoneal injections of gefitinib between weeks 12 and 18. In rats treated with gefitinib, the number of HCC nodules was significantly lower than in untreated rats (18.1 ± 2.4 vs. 3.7 ± 0.45; P < .05), while EGFR was activated to a lesser extent in the diseased and tumoral tissues of these animals compared with untreated rats. HCC nodules from both untreated and gefitinib‐treated animals displayed insulin‐like growth factor 2 overexpression that contributed to tumor formation in treated animals. In conclusion, the blockade of EGFR activity by gefitinib has an antitumoral effect on the development of HCC in DEN‐exposed rats, suggesting that it may provide benefit for the chemoprevention of HCC. (HEPATOLOGY 2005,41:307–314.)

Comparison of the Glidescope®, the McGrath®, the Airtraq® and the Macintosh laryngoscopes in simulated difficult airways*

Several indirect laryngoscopes have recently been developed, but relatively few have been formally compared. In this study we evaluated the efficacy and the usability of the Macintosh, the Glidescope®, the McGrath® and the Airtraq® laryngoscopes. Sixty anaesthesia providers (20 staff, 20 residents, and 20 nurses) were enrolled into this study. The volunteers intubated the trachea of a Laerdal SimMan® manikin in three simulated difficult airway scenarios. In all scenarios, indirect laryngoscopes provided better laryngeal exposure than the Macintosh blade and appeared to produce less dental trauma. In the most difficult scenario (tongue oedema), the Macintosh blade was associated with a high rate of failure and prolonged intubation times whereas indirect laryngoscopes improved intubation time and rarely failed. Indirect laryngoscopes were judged easier to use than the Macintosh. Differences existed between indirect devices. The Airtraq® consistently provided the most rapid intubation. Laryngeal grade views were superior with the Airtraq® and McGrath® than with the Glidescope®.

Effects of thoracic extradural block on diaphragmatic electrical activity and contractility after upper abdominal surgery

BackgroundUpper abdominal surgery (UAS) induces diaphragmatic dysfunction. Thoracic extradural block (TEB) using 0.5% bupivacaine improves some pressure and motion indices of diaphragmatic function. However, no direct information on diaphragmatic activity is available after UAS. The aim of this study was to assess diaphragmatic electrical activity (Edi) after UAS before and after TEB. MethodsA postoperative electromyogram was obtained, using intramuscular electrodes inserted by the surgeon in the costal and crural parts of the diaphragm, in 14 patients undergoing abdominal aortic surgery. Tidal changes in abdominal (VAB) and rib-cage (VRC) volumes, and gastric (ΔPgas), esophageal (ΔPes), and transdiaphragmatic (ΔPdi) pressures were used to measure tidal volume (VT) and respiratory rate and to provide indirect indices of diaphragmatic activity from the two ratios VAB/VT and ΔPgas/ΔPdi. These respiratory variables were obtained preoperatively. Postoperatively, measurements including Edi were obtained before and after a seg-mental epidural block, reaching a T4 level was achieved with 0.5% plain bupivacaine. ResultsUpper abdominal surgery induced an increase in respiratory rate (+28 ± 15%; P <.01), associated with a decrease in VAB/VT (from 0.75 ± 0.11 to 0.07 ± 0.08; P <.01), ΔPgas/ΔPdi (from 0.3 ± 0.08 to 0.01 ± 0.19; P <.05), and VT (30 ± 14%; P<.01). After surgery, all patients exhibited electrical diaphragmatic activity that increased with TEB by 48 ± 28% (P <.01) and 60 ± 22% (P <.001) for the cural and costal segments, respectively. The ratio ΔPdi/Edi, used to evaluate diaphragmatic contractility, was not modified by TEB. Tidal volume, respiratory rate, and ΔPgas/ΔPdi returned to preoperative levels, whereas VAB/VT increased but remained different from preoperative values. ConclusionsThis study demonstrates that TEB produces an increase in diaphragmatic activity, identical for the two segments of the muscle. Interruption of afferents that produce an inhibitory effect on diaphragmatic activity appears the most attractive hypothesis to explain the consequences of TEB after UAS.

Reduction of Urinary Tract Infection and Antibiotic Use after Surgery: A Controlled, Prospective, Before-After Intervention Study

BACKGROUND Urinary tract infection is the most frequent health care-associated complication. We hypothesized that the implementation of a multifaceted prevention strategy could decrease its incidence after surgery. METHODS In a controlled, prospective, before-after intervention trial with 1328 adult patients scheduled for orthopedic or abdominal surgery, nosocomial infection surveillance was conducted until hospital discharge. A multifaceted intervention including specifically tailored, locally developed guidelines for the prevention of urinary tract infection was implemented for orthopedic surgery patients, and abdominal surgery patients served as control subjects. Infectious and noninfectious complications, adherence to guidelines, and antibiotic use were monitored before and after the intervention and again 2 years later. RESULTS The incidence of urinary tract infection decreased from 10.4 to 3.9 episodes per 100 patients in the intervention group (incidence-density ratio, 0.41; 95% CI, 0.20-0.79; P=.004). Adherence to guidelines was 82.2%. Both the frequency and the duration of urinary catheterization decreased following the intervention. Recourse to antibiotic therapy after surgery dropped in the intervention group from 17.9 to 15.6 defined daily doses per 100 patient-days (P<.005) because of a reduced need for the treatment of urinary tract infection (P<.001). Follow-up after 2 years revealed a sustained impact of the strategy and a subsequent low use of antibiotics, consistent with stable adherence to guidelines (80.8%). CONCLUSIONS A multifaceted prevention strategy can dramatically decrease postoperative urinary tract infection and contribute to the reduction of the overall use of antibiotics after surgery.

Learning curves of the Glidescope, the McGrath and the Airtraq laryngoscopes: a manikin study.

Background and objective Several video and optical laryngoscopes have been developed but few have been compared in terms of their learning curves and efficacy. Using a manikin with normal airways we compared the Glidescope, the McGrath, the Airtraq and the Macintosh laryngoscopes. Methods Sixty anaesthetists (20 staff, 20 residents and 20 nurses) participated in the study. All subjects were novice with the new devices. They intubated a Laerdal SimMan manikin (with normal airway) five times in a row with all laryngoscopes. The sequence of use of the devices was randomized. Before using a device, a presentation and a demonstration were provided. Outcome measures were: duration of intubation attempt, modified Cormack grades, dental trauma and difficulty of use. Results The Airtraq had the most favourable learning curve and mirrored the Macintosh after two intubation attempts. The Glidescope and McGrath had steep learning curves but, after five attempts, differences persisted when compared with the Macintosh and Airtraq. Time taken to visualize the glottis was similar but time taken to position the endotracheal tube was shorter for the Airtraq when compared with the Glidescope and McGrath. Indirect laryngoscopes seemed to have advantages over the Macintosh blade in terms of laryngeal exposure and potential dental trauma. Conclusions In a ‘normal airway’ model, intubation skills with the new devices appeared to be rapidly mastered. The three indirect laryngoscopes provided a better glottic exposure than the Macintosh. The Airtraq displayed the most favourable learning curve, probably reflecting differences in the techniques of endotracheal tube placement: guiding channel versus steering technique.

Ventilatory pattern and chest wall mechanics during ketamine anesthesia in humans

The effects of anesthetic doses of ketamine (iv bolus of 3 mg · kg−1 followed by a continuous infusion of 20 μg · kg−1 · min−1) on functional residual capacity (FRC) measured by the helium dilution method and on the breathing pattern recorded by a noninvasive method (NIM) based on chest wall circumference changes were studied in 14 ASA P.S.I patients. Ketamine anesthesia was associated with: 1) the maintenance of FRC, minute ventilation, and tidal volume; 2) an increase in rib cage contribution to tidal breathing; and 3) an alteration of volume-motion relationships of the chest wall compartments. It is concluded that: 1) in contrast to volatile anesthetic agents, ketamine anesthesia has a sparing effect on intercostal muscle activity, which may explain the maintenance of FRC; and 2) changes in chest wall geometry and compliance induced by anesthetic agents must be taken into account for NIM to be valid.

The influence of an aging surgical population on the anesthesia workload: a ten-year survey

To assess the evolution of the anesthetic workload related to elderly population (>or=to65 yr) at the University Hospital of Geneva, the total number of anesthesia cases, high-risk patients, and emergency procedures, as well as the total duration of anesthesia and incidence of perianesthetic complications, were retrospectively analyzed over 10 yr. The squared correlation coefficient was used to assess the proportion of variance explained by the linear regression of the absolute and the relative number of events over time. More than 165,000 anesthesia procedures were analyzed, and the data were separated into two groups: the younger population (<65 yr) and the elderly population (>or=to65 yr). From 1985 to 1994, the elderly surgical population grew significantly faster (P < 0.001) than the elderly resident population (from 20.3% to 25.1% versus from 12.5% to 13.6%). Half of the increased number of anesthesia cases during this period were administered to elderly patients. The number of high-risk elderly patients increased by 48.3% (P < 0.0001). The number of emergency procedures in elderly patients increased only until 1991, and a significant decrease in the incidence of perianesthetic complications was observed. Because the mean duration of each procedure remained constant, the increased anesthetic workload in our institution was mainly due to increased geriatric surgical activity. Implications: During a study period of 10 yr, the increased anesthetic workload (defined as the number of anesthesia cases, high-risk patients, emergency procedures, and complication rate) at the University Hospital of Geneva was mainly due to the increased geriatric (patients >or=to65 yr) surgical activity, not to the aging of the resident population. (Anesth Analg 1998;86:1165-70)

Hospital-wide surveillance of catheter-related bloodstream infection: from the expected to the unexpected.

Catheter-related bloodstream infections (CRBSIs) are among the most frequent healthcare-associated infections and cause considerable morbidity, mortality, and resource use. CRBSI surveillance serves quality improvement, but is often restricted to intensive care units (ICUs). We conducted a four-month prospective cohort study of all non-cuffed central venous catheters (CVCs) to design an efficient CRBSI surveillance and prevention programme. CVCs were assessed on a daily basis for ward exposure time, care parameters, and the occurrence of laboratory-confirmed CRBSI. Overall, 248 patients with 426 CVCs accounted for 3567 CVC-days (median: 5) and 15 CRBSI episodes. CVCs were inserted by anaesthetists, ICU physicians and internists in 45%, 47%, and 8% of cases, respectively. CVC utilisation rates for intensive care, internal medicine, non-abdominal surgery and abdominal surgery were 29.8, 3.8, 1.7 and 4.9 per 100 patient-days, respectively. Fourteen percent of patients changed wards while having a CVC in place, so spending CVC-days at risk within multiple departments. CRBSI incidence densities for ICU, internal medicine, surgery and abdominal surgery were 5.6, 1.9, 2.4 and 7.7 per 1000 CVC-days at risk, respectively. In a univariate Cox proportional hazards model, the high CRBSI rate in abdominal surgery was associated with longer CVC duration, frequent use of parenteral nutrition and CVC insertion by anaesthetists. CRBSI numbers were insufficient to perform a multivariate analysis. Our surveillance revealed similar CRBSI rates in both ICU and non-ICU departments, and when frequent ward transfers occurred. Hospital-wide CRBSI surveillance is advisable when a large proportion of CVC-days occur outside the ICU.

Hand-cleansing during postanesthesia care.

Background Transmission of microorganisms from the hands of healthcare workers is the main source of cross-infection and can be prevented by hand-cleansing. The authors assessed the compliance rate with hand-cleansing practices in the postanesthesia care unit and investigated factors associated with noncompliance. Methods Patient care activities, indications for and compliance of postanesthesia care unit staff with hand-cleansing, defined as either washing hands with soap and water or rubbing hands with alcohol, were monitored at the time of patient admission and during their stay. Multivariate analysis identified predictors of noncompliance with hand-cleansing on admission after adjustment for confounders. Results A total of 3,143 patient care activities, including 1,091 opportunities for hand-cleansing at high or medium risk for cross-transmission, were recorded among 187 patients. The higher the workload, the higher the number of indications for hand-cleansing and the lower the compliance. Average compliance with hand-cleansing at postanesthesia care unit admission was 19.6%. Independent predictors for noncompliance included caring for patients older than 65 yr (odds ratio, 2.23; 95% confidence interval, 1.40–3.57) and those recovering from clean/clean–contaminated surgery (odds ratio, 2.27; 95% confidence interval, 1.11–4.76), as well as high intensity of patient care (odds ratio, 1.01 per patient care activity; 95% confidence interval, 1.0–1.02). Compliance with hand-cleansing for patients already admitted to the postanesthesia care unit was 12.5%. Conclusions Failure to cleanse hands during patient care is common in the postanesthesia care unit and is associated with identifiable factors. The close relation between the intensity of patient care and noncompliance argues that hand-cleansing should not be viewed as a problematic individual behavior only, and system change must be considered in prevention strategies.