Amélioration de l’accès préemptif à la liste d’attente de transplantation rénale entre 2017 et 2021 : bilan d’un programme régional en Aquitaine

Introduction

Pre-emptive access to the kidney transplant (KT) waiting list remains limited in France, with only 3.9% of patients on pre-emptive KT and 5.6% of patients registered at the time of initiation of dialysis. A similar trend was observed in Aquitaine. The aim of this study was to assess the impact of a regional program in terms of access to the waiting list for patients initiating a kidney replacement therapy (KRT).

Methods

We included all patients assessed for registration on the list between 2017 and 2020, 2017 being the reference year and 2018 the beginning of the program. Using the CRISTAL and REIN registries, we assessed changes in the number of patients on the list at the time of initiation of dialysis or transplantation.

Results

The number of new assessed candidates increased gradually each year from 255 in 2017 to 352 in 2020 (+38%). The number of patients on the list sharply increased in 2018 from 229 in 2017 to 319 in 2018 (+39.3%) and then remained stable. At the initiation of KRT, the proportion of patients registered on the waiting list increased gradually from 7.1% in 2017 to 18.2% in 2020. The proportion of pre-emptive KT remained stable between 2017 and 2021 (around 7%) with a decrease in 2020 (4.6%). Approximately 60% of patients had a contraindication to transplantation throughout the study.

Conclusion

This study showed that a regional program aimed at providing better information to healthcare professionals and patients and encouraging rapid assessment of transplant candidates could increase the rate of pre-emptive registration on the KT waiting list for eligible patients over 4 years.

Nurse-led coordinated surgical care pathways for cost optimization of robotic-assisted partial nephrectomy: medico-economic analysis of the UroCCR-25 AMBU-REIN study

PURPOSE

Robot-assisted partial nephrectomy (RAPN) reduces morbidity, enabling development of Enhanced Recovery After Surgery (ERAS) and day-case protocols. Additional financial costs limit its integration into clinical practice. We evaluated the medico-economic impact of RAPN using a nurse-led coordinated pathway of care (NLC-RAPN).

METHODS

All tumor RAPNs performed in 2017 were prospectively included in nurse-led protocols: NP-RAAC (ERAS) or Ambu-Rein (day case). Clinico-biological and pathological data were prospectively collected within the French Research Network for Kidney Cancer database (NCT03293563). Estimated costs were compared to "average" patients at the national level operated by open partial nephrectomy (OPN) or RAPN, using data from the 2017 French hospital discharge database and the national cost scale.

RESULTS

The NLC-RAPN cohort (n = 151) included 27 (18%) outpatients and the average hospital length of stay (LOS) was 2.4 days. In the national control cohorts for OPN (n = 2475) and RAPN (n = 3529), the average LOS were 8.0 and 5.2 days, respectively. The mean incomes per group were €7607 for NLC-RAPN, €9813 for OPN, and €8215 for RAPN. The mean daily cost of stay was €659 for NLC-RAPN, €838 for OPN, and €725 for RAPN. The overall cost for NLC-RAPN was €6594, €8733 for OPN, and €8763 for RAPN. The best operational margin was obtained for day-case NLC-RAPN (€1967).

CONCLUSION

Combining RAPN with nurse-led coordinated pathways of care led to a shorter hospital stay and reduced costs versus OPN. This may facilitate the economic sustainability of robotic assistance for hospitals where the extra cost is not covered by the healthcare system.

A national healthcare response to intensive care bed requirements during the COVID-19 outbreak in France

Background

Whereas 5415 Intensive Care Unit (ICU) beds were initially available, 7148 COVID-19 patients were hospitalised in the ICU at the peak of the outbreak. The present study reports how the French Health Care system created temporary ICU beds to avoid being overwhelmed.

Methods

All French ICUs were contacted for answering a questionnaire focusing on the available beds and health care providers before and during the outbreak.

Results

Among 336 institutions with ICUs before the outbreak, 315 (94%) participated, covering 5054/5531 (91%) ICU beds. During the outbreak, 4806 new ICU beds (+95% increase) were created from Acute Care Unit (ACU, 2283), Post Anaesthetic Care Unit and Operating Theatre (PACU & OT, 1522), other units (374) or real build-up of new ICU beds (627), respectively. At the peak of the outbreak, 9860, 1982 and 3089 ICU, ACU and PACU beds were made available.

Before the outbreak, 3548 physicians (2224 critical care anaesthesiologists, 898 intensivists and 275 from other specialties, 151 paediatrics), 1785 residents, 11,023 nurses and 6763 nursing auxiliaries worked in established ICUs. During the outbreak, 2524 physicians, 715 residents, 7722 nurses and 3043 nursing auxiliaries supplemented the usual staff in all ICUs. A total number of 3212 new ventilators were added to the 5997 initially available in ICU.

Conclusion

During the COVID-19 outbreak, the French Health Care system created 4806 ICU beds (+95% increase from baseline), essentially by transforming beds from ACUs and PACUs. Collaboration between intensivists, critical care anaesthesiologists, emergency physicians as well as the mobilisation of nursing staff were primordial in this context.

[Cardiac arrest secondary to pacemaker dysfunction during general anesthesia in a young adult patient]

The number of patients with cardiac pacemaker is continuously increasing. The anesthetic management of these patients is often trivialized, particularly during minor surgery. However there is always a potential risk of dysfunction during anesthesia. Perioperative management of these patients must be careful and standardized to avoid accidents. We report a case of cardiac arrest during general anesthesia for a day-surgery secondary to pacemaker dysfunction by increasing pacing thresholds in a young adult patient. Rapid onset after induction, without any surgical stimulation, has raised the question of the involvement of anesthetic drugs like propofol.

Abilities of pulse pressure variations and stroke volume variations to predict fluid responsiveness in prone position during scoliosis surgery

BACKGROUND

Pulse pressure variation (PPV) and stroke volume variation (SVV) are robust indicators of fluid responsiveness in mechanically ventilated supine patients. The aim of the study was to evaluate the ability of PPV and SVV to predict fluid responsiveness in mechanically ventilated patients in the prone position (PP) during scoliosis surgery.

METHODS

Thirty subjects were studied after the induction of anaesthesia in the supine position [before and after volume expansion (VE) with 500 ml of hetastarch 6%] and in PP (immediately after PP and before and after VE). PPV, SVV, cardiac output (CO), and static compliance of the respiratory system were recorded at each interval. Subjects were defined as responders (Rs) to VE if CO increased > or =15%.

RESULTS

Three subjects were excluded. In the supine position, 16 subjects were Rs. PPV and SVV before VE were correlated with VE-induced changes in CO (r(2)=0.64, P<0.0001 and r(2)=0.56, P<0.0001, respectively). Fluid responsiveness was predicted by PPV >11% (sensitivity=88%, specificity=82%) and by SVV >9% (sensitivity=88%, specificity=91%). PP induced an increase in PPV and SVV (P<0.0001) and a decrease in the static compliance of the respiratory system (P<0.0001). In PP, 17 patients were Rs. PPV and SVV before VE were correlated with VE-induced changes in CO (r(2)=0.59, P<0.0001 and r(2)=0.55, P<0.0005, respectively). Fluid responsiveness was predicted in PP by PPV >15% (sensitivity=100%, specificity=80%) and by SVV >14% (sensitivity=94%, specificity=80%).

CONCLUSIONS

PP induces a significant increase in PPV and SVV but does not alter their abilities to predict fluid responsiveness.

Pressure-controlled ventilation is superior to volume-controlled ventilation with a laryngeal mask airway in children

BACKGROUND

This prospective, randomized, crossover study had two purposes: first, to determine whether pressure-controlled ventilation (PCV) is safer than volume-controlled ventilation (VCV) by preventing gastric insufflation in children ventilated through an laryngeal mask airway (LMA); second, to assess whether the measurement of LMA leak pressure (P(leak)) is useful for preventing leakage during positive pressure ventilation (PPV).

METHODS

Forty-one, 2 to 15-year-old children underwent general anesthesia with an LMA. The expiratory valve was set at 30 cmH(2)O and P(leak) was measured using constant gas flow. Children were randomly ventilated using PCV or VCV for 5 min in order to reach a P(ET)CO(2) not exceeding 45 mm Hg, and then they were ventilated with the alternative mode. If the target P(ET)CO(2) could not be obtained in one mode, we switched to the other. If both modes failed, children were intubated. Tidal volumes, P(ET)CO(2) and airway pressures were noted and compared between modes. Gastric insufflation was checked by epigastric auscultation.

RESULTS

PCV provided more efficient ventilation than VCV, as targeted P(ET)CO(2) was obtained without gastric insufflation using PCV in all cases except one, whereas VCV failed in three cases. No gastric insufflation occurred when ventilating below peak.

CONCLUSIONS

These findings suggest that in the age group studied, PCV is more efficient than VCV for controlled ventilation with a laryngeal mask. Gastric insufflation did not occur with this mode.