Nathalie Nathan

Target-controlled inhalation anaesthesia: A cost-benefit analysis based on the cost per minute of anaesthesia by inhalation.

BACKGROUND End-tidal target-controlled inhalational anaesthesia (TCIA) with halogenated agents (HA) provides a faster and more accurately titrated anaesthesia as compared to manually-controlled anaesthesia. This study aimed to measure the macro-economic cost-benefit ratio of TCIA as compared to manually-controlled anaesthesia. METHODS This retrospective and descriptive study compared direct drug spending between two hospitals before 2011 and then after the replacement of three of six anaesthesia machines with TCIA mode machines in 2012 (Aisys carestation®, GE). The direct costs were obtained from the pharmacy department and the number and duration of the anaesthesia procedures from the computerized files of the hospital. RESULTS The cost of halogenated agents was reduced in the hospital equipped with an Aisys carestation® by 13% as was the cost of one minute of anaesthesia by inhalation (€0.138 and €0.121/min between 2011 and 2012). The extra cost of the implementation of the 3 anaesthesia machines could be paid off with the resulting savings over 6 years. DISCUSSION TCIA appears to have a favourable cost-benefit ratio. Despite a number of factors, which would tend to minimise the saving and increase costs, we still managed to observe a 13% savings. Shorter duration of surgery, type of induction as well as the way HA concentration is targeted may influence the savings results obtained.

Value of Lung Sonography to Control Right-Sided Double Lumen Endotracheal Tube Location

Lung isolation is mandatory during Lung surgery [1]. The most useful device to achieve Lung isolation is the use of double lumen endotracheal tube (DLT). The Gold Standard to assess DLT position remains fibroscopy because pulmonary auscultation alone isn’t accurate enough to ensure correct DLT correct position. Fibroscopic verification of blind insertion of DLT shows malposition of 78% left-sided DLT and 83% of right-sided DLT [2]. Moreover fibroscopic checking is mandatory whenever a right-sided DLT is used, to prevent right upper lobe (RUL) isolation [3]. Right-sided DLT is usually required during left pneumonectomy, but also for lobectomy each time the surgeon plans left lung may be incomplete. The use of fibrocopy may be timeconsuming and requires specific small sized fibroscopes whose optical fibers may be broken during the passage through the tracheal tube.

Management of antiplatelet therapy in patients undergoing elective invasive procedures: Proposals from the French Working Group on perioperative hemostasis (GIHP) and the French Study Group on thrombosis and hemostasis (GFHT). In collaboration with the French Society for Anesthesia and Intensive Care (SFAR).

The French Working Group on Perioperative Haemostasis (GIHP) and the French Study Group on Haemostasis and Thrombosis (GFHT) in collaboration with the French Society for Anaesthesia and Intensive Care Medicine (SFAR) drafted up-to-date proposals for the management of antiplatelet therapy in patients undergoing elective invasive procedures. The proposals were discussed and validated by a vote; all proposals but one could be assigned with a high strength. The management of antiplatelet therapy is based on their indication and the procedure. The risk of bleeding related to the procedure can be divided into high, moderate and low categories depending on the possibility of performing the procedure in patients receiving antiplatelet agents (none, monotherapy and dual antiplatelet therapy respectively). If discontinuation of antiplatelet therapy is indicated before the procedure, a last intake of aspirin, clopidogrel, ticagrelor and prasugrel 3, 5, 5 and 7 days before surgery respectively is proposed. The thrombotic risk associated with discontinuation should be assessed according to each specific indication of antiplatelet therapy and is higher for patients receiving dual therapy for coronary artery disease (with further refinements based on a few well-accepted items) than for those receiving monotherapy for cardiovascular prevention, for secondary stroke prevention or for lower extremity arterial disease. These proposals also address the issue of the potential role of platelet functional tests and consider management of antiplatelet therapy for regional anaesthesia, including central neuraxial anaesthesia and peripheral nerve blocks, and for coronary artery surgery.

A Dramatic Transport Respirator Failure

Failure of the anaesthesia workstation is largely described in the anaesthesia literature but there is few descriptions of such hazards with transport ventilators [1-4]. This clinical case reports a transport ventilator severe failure leading to death and whose diagnosis was delayed because anesthesiologist attention was distracted to solve other priorities. This type of failure highlights also organization and apparatus maintenance dysfunction and the importance of human defect of attention as the root causes of severe adverse events.