Preoperative ketamine administration for prevention of postoperative neurocognitive disorders after major orthopedic surgery in elderly patients: A multicenter randomized blinded placebo-controlled trial.

BACKGROUND: Preventive anesthetic impact on the high rates of postoperative neurocognitive disorders in elderly patients is debated. The Prevention of postOperative Cognitive dysfunction by Ketamine (POCK) study aimed to assess the effect of ketamine on this condition. METHODS: This is a multicenter, randomized, double-blind, interventional study. Patients ≥60 years undergoing major orthopedic surgery were randomly assigned in a 1:1 ratio to receive preoperative ketamine 0.5 mg/kg as an intravenous bolus (n = 152) or placebo (n = 149) in random blocks stratified according to the study site, preoperative cognitive status and age. The primary outcome was the proportion of objective delayed neurocognitive recovery (dNR) defined as a decline of one or more neuropsychological assessment standard deviations on postoperative day 7. Secondary outcomes included a three-month incidence of objective postoperative neurocognitive disorder (POND), as well as delirium, anxiety, and symptoms of depression seven days and three months after surgery. RESULTS: Among 301 patients included, 292 (97%) completed the trial. Objective dNR occurred in 50 (38.8%) patients in the ketamine group and 54 (40.9%) patients in the placebo group (OR [95% CI] 0.92 [0.56; 1.51], p = 0.73) on postoperative day 7. Incidence of objective POND three months after surgery did not differ significantly between the two groups nor did incidence of delirium, anxiety, apathy, and fatigue. Symptoms of depression were less frequent in the ketamine group three months after surgery (OR [95% CI] 0.34 [0.13-0.86]). CONCLUSIONS: A single preoperative bolus of intravenous ketamine does not prevent the occurrence of dNR or POND in elderly patients scheduled for major orthopedic surgery. (Clinicaltrials.gov NCT02892916).

Ventilator-associated pneumonia in patients assisted by veno-arterial extracorporeal membrane oxygenation support: Epidemiology and risk factors of treatment failure.

INTRODUCTION: Ventilator-associated pneumonia (VAP) is frequent in Intensive Care Unit (ICU) patients. In the specific case of patients treated with Veno-Arterial Extracorporeal Membrane Oxygenation Support (VA-ECMO), VAP treatment failures (VAP-TF) have been incompletely investigated. METHODS: To investigate the risk factors of treatment failure (VAP-TF) in a large cohort of ICU patients treated with VA-ECMO, we conducted a retrospective study in a Surgical ICU about patients assisted with VA-ECMO between January 1, 2013, and December 31, 2014. Diagnosis of VAP was confirmed by a positive quantitative culture of a respiratory sample. VAP-TF was defined as composite of death attributable to pneumonia and relapse within 28 days of the first episode. RESULTS: In total, 152 patients underwent ECMO support for > 48h. During the VA-ECMO support, 85 (55.9%) patients developed a VAP, for a rate of 60.6 per 1000 ECMO days. The main pathogens identified were Pseudomonas aeruginosa and Enterobacteriaceae. VAP-TF occurred in 37.2% of patients and was associated with an increased 28-day mortality (Hazard Ratio 3.05 [1.66; 5.63], P<0.001), and VA-ECMO assistance duration (HR 1.47 [1.05-2.05], P = 0.025). Risk factors for VAP-TF were renal replacement therapy (HR 13.05 [1.73; 98.56], P = 0.013) and documentation of Pseudomonas aeruginosa (HR 2.36 [1.04; 5.35], P = 0.04). CONCLUSIONS: VAP in patients treated with VA-ECMO is associated with an increased morbidity and mortality. RRT and infection by Pseudomonas aeruginosa appear as strong risks factors of treatment failure. Further studies seem necessary to precise the best antibiotic management in these patients.

Efficacy and safety of ultrasound-guided distal blocks for analgesia without motor blockade after ambulatory hand surgery.

PURPOSE: To assess the suitability of ultrasound-guided (USG), single-injection distal block(s) for pain management after outpatient hand and wrist bone surgery. METHODS: We conducted a retrospective review of 125 of 198 consecutive ambulatory surgery patients who underwent hand and wrist bone surgery between June 2010 and January 2012. All patients received a USG axillary block using a short-acting local anesthetic (lidocaine) and secondary 1, 2, or 3 (median, radial, or ulnar) USG distal analgesic block(s) using a long-acting local anesthetic (ropivacaine). All patients were contacted by phone on the first postoperative day. All patients received a concomitant prescription of acetaminophen and nonsteroidal anti-inflammatory drugs with opioids as a rescue treatment. Effectiveness and duration of the distal nerve blocks, compliance with analgesic treatment and rescue opioids requirement, opioid-related side effects, prolonged upper limb motor block, quality of sleep on first postoperative night, and patient satisfaction were evaluated. RESULTS: Most distal analgesic blocks were effective (120 of 125; 96%), with an average duration of nearly 12 hours On the first day after surgery, 28 patients (23%) had a numeric verbal scale greater than 3, although 14 of them had taken the rescue opioids. No patient reported prolonged motor blockade or insensate limb. Opioid-related side effects occurred in 23% of patients. CONCLUSIONS: After hand and wrist bone surgery, USG selective distal blocks using a long-acting local anesthetic, combined with oral analgesics, were effective in a large majority of patients. However, pain control was suboptimal for some especially painful procedures such as wrist surgery, trapeziometacarpal arthrodesis, and finger amputation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.