Erector spinae plane block did not improve postoperative pain-related outcomes and recovery after video-assisted thoracoscopic surgery : a randomised controlled double-blinded multi-center trial.

INTRODUCTION: There is a sizable niche for a minimally invasive analgesic technique that could facilitate ambulatory video-assisted thoracoscopic surgery (VATS). Our study aimed to determine the analgesic potential of a single-shot erector spinae plane (ESP) block for VATS. The primary objective was the total hydromorphone consumption with patient-controlled analgesia (PCA) 24 h after surgery. METHODS: We conducted a randomized, controlled, double-blind study with patients scheduled for VATS in two major university-affiliated hospital centres. We randomized 52 patients into two groups: a single-shot ESP block using bupivacaine or an ESP block with normal saline (control). We administered a preoperative and postoperative (24 h) quality of recovery (QoR-15) questionnaire and assessed postoperative pain using a verbal numerical rating scale (VNRS) score. We evaluated the total standardized intraoperative fentanyl administration, total postoperative hydromorphone consumption (PCA; primary endpoint), and the incidence of adverse effects. RESULTS: There was no difference in the primary objective, hydromorphone consumption at 24 h (7.6 (4.4) mg for the Bupivacaine group versus 8.1 (4.2) mg for the Control group). Secondary objectives and incidence of adverse events were not different between the two groups at any time during the first 24 h following surgery. CONCLUSION: Our multi-centre randomized, controlled, double-blinded study found no advantage of an ESP block over placebo for VATS for opioid consumption, pain, or QoR-15 scores. Further studies are ongoing to establish the benefits of using a denser block (single-shot paravertebral with a continuous ESP block), which may provide a better quality of analgesia.

[Muscle relaxant and reversal practices and impact of reversal modalities on operating room and postoperative room duration - results of a Delphi study]. / Pratiques de curarisation/décurarisation et impact des modalités de décurarisation sur les durées en salle opératoire et SSPI ­ résultats d'une enquête Delphi.

OBJECTIVE: The objectives of this Delphi study are to describe muscle relaxant and reversal practices in France and to seek a consensus on the impact of the reversal method on the time spent in the OR and PACU. METHOD: A two-round Delphi survey was conducted on a panel of French anesthetists involved in colectomies, hysterectomies or bariatric surgery. The questionnaire was designed in collaboration with a scientific committee and was intended to assess neuromuscular blockade reversal techniques and their impact on time spent in the OR and PACU. The first round gathered data on practices and the second round sought a consensus for the time aspect. RESULTS: Overall, all participants (99%) monitored neuromuscular blockade, with a majority (82%) doing so continuously. Of the participants, 22% routinely used a reversal drug. The time saved in the OR or PACU with sugammadex varied between 1 and 43 minutes depending on the surgery and the neuromuscular blockade reversal method it was compared to. CONCLUSION: Although SFAR recommendations (French Society of Anesthesia & Intensive Care Medicine) were generally well followed, the use of neuromuscular blockade reversal drugs was observed to be not fully integrated into regular practice, despite the fact that more than half of patients were reported to have residual neuromuscular blockade post-surgery and that sugammadex is known to reduce time spent in the OR and PACU compared to other neuromuscular blockade reversal methods.

Example of cost calculations for an operating room and a post-anaesthesia care unit.

OBJECTIVE: The aim of this study was to evaluate the cost of an operating room using data from our hospital. Using an accounting-based method helped us. METHODS: Over the year 2012, the sum of direct and indirect expenses with cost sharing expenses allowed us to calculate the cost of the operating room (OR) and of the post-anaesthesia care unit (PACU). RESULTS: The cost of the OR and PACU was €10.8 per minute of time offered. Two thirds of the direct expenses were allocated to surgery and one third to anaesthesia. Indirect expenses were 25% of the direct expenses. The cost of medications and single use medical devises was €111.45 per anaesthesia. The total cost of anaesthesia (taking into account wages and indirect expenses) was €753.14 per anaesthesia as compared to the total cost of the anaesthesia. The part of medications and single use devices for anaesthesia was 14.8% of the total cost. CONCLUSION: Despite the difficulties facing cost evaluation, this model of calculation, assisted by the cost accounting controller, helped us to have a concrete financial vision. It also shows that a global reflexion is necessary during financial decision-making.

[Prolonged phase II neuromuscular blockade following succinylcholine administration]. / Bloc dépolarisant de phase II et curarisation prolongée après un bolus de succinylcholine.

Patients who are given a single dose of succinylcholine normally undergo a short-acting depolarizing phase I neuromuscular block but rarely a phase II block. Prolonged neuromuscular blockade occurs after a single dose of succinylcholine in case of genetically determined abnormal plasma butyrylcholinesterase activity. It is mandatory to use monitoring to detect this side effect. We report a case of a patient with abnormal plasma butyrylcholinesterase activity undergoing a six-hour prolonged neuromuscular phase II block, after a single dose of succinylcholine.

Neuraxial anesthesia in patients with intracranial hypertension or cerebrospinal fluid shunting systems: what should the anesthetist know?

The management of patients with central nervous system disorders such as brain tumours, hydrocephalus, intracranial hypertension, or subarachnoid hemorrhage has improved in recent years resulting in increased life expectancy. Consequently, the prevalence of patients with increased intracranial pressure or cerebrospinal fluid shunting devices presenting for non-neurological procedures has increased. These patients commonly receive a general anesthetic, as the safety profile of neuraxial anesthesia in this clinical setting remains uncertain. This article reviews literature on neuraxial anesthesia in patients with intracranial hypertension or cerebrospinal fluid shunting systems. It describes current knowledge, exposes and weighs the real benefits and risks of this technique in this setting. It provides several scenarios and anesthetic options to help the practitioner with choosing a tailored approach in this specific population.

[Enhanced recovery following uncomplicated elective caesarean section in France: a survey of national practice]. / Réhabilitation périopératoire des césariennes programmées non compliquées en France : enquête de pratique nationale.

INTRODUCTION: Enhanced recovery is a concept currently recognised and adopted in a number of surgical specialties. In obstetrics however, this concept remains surprisingly underdeveloped. The purpose of this survey was to study the practice of obstetric anaesthetists in France as regards the recovery of women undergoing uncomplicated, elective caesarean section. MATERIAL AND METHOD: An online 39-point questionnaire was displayed for 2months on the Caro (Club d'anesthesie réanimation en obstétrique) website. The questionnaire related to uncomplicated, elective Caesarean sections and aimed to define the following: preoperative information given regarding the recovery period, intraoperative care - both anaesthetic and surgical, postoperative analgesia, measures taken to prevent post-partum haemorrhage, reintroduction of fluids and diet, return to mobility, local practices designed to promote bonding between mother and baby. RESULTS: The overall response rate for our survey was 45%. Forty-nine percent of practitioners report that patients are provided with specific information on the recovery period preoperatively. Sixty percent of those surveyed state the absence of any specific recovery protocol for this patient population in their hospital. Eighty-one percent of respondents state that, in the majority of cases, patients are admitted on the eve of surgery and remain hospitalised for more than 72hours (89%). Ninety-nine percent of practitioners employ a regional technique to deliver anaesthesia for elective section and 44% rely on intrathecal morphine for postoperative analgesia. The concept of 'Patient Controlled Oral Analgesia' (PCOA), although widely recognised, is used by only 17% of practitioners. Forty-one percent of practitioners report the reintroduction of fluids as soon as patients return to the ward following surgery and at the same time as the urinary catheter is removed (51%). Diet is commenced 4 to 6hours following surgery amongst 40% of those surveyed. Fifty-one percent of practitioners report removal of the intravenous catheter 24hours postoperatively. Finally, 49% of practitioners feel patients are independently functioning and mobile within 24hours of surgery. CONCLUSION: This survey of national practice shows that the concept of 'enhanced recovery' following elective caesarean section can be again developed. Standardisation of practice with the design of local protocols relating to postoperative analgesia, timing of removal of the intravenous access and urinary catheter, time to first mobilisation and to commencement of diet would appear to be warranted. Surely this surgery, more than any other, merits an expeditious and effective return to normal and independent function, allowing mother to better look after baby.

[Medical termination of pregnancy in a patient with severe cystic fibrosis. Possible effect of the antiglucocorticoid action of mifepristone on the respiratory disease]. / Interruption médicale de grossesse chez une patiente atteinte d'une mucoviscidose sévère. Impact potentiel de l'effet antiglucocorticoïde de la mifépristone sur la pathologie respiratoire.

Better management of patients with cystic fibrosis has resulted in an increased rate of pregnancy, especially in mild forms. In case of severe respiratory impairment, physiological changes occurring during pregnancy can be life threatening. Medical termination of pregnancy may be necessary. We report a case of severe cystic fibrosis requiring a termination of pregnancy due to significant maternal risk at 17 weeks of gestation. Mifepristone used for induction of labor has a well-known antiglucocorticoid action. We discuss here its potential effect on the onset of an acute pulmonary failure in this patient with long-term corticosteroid therapy.

[Prolonged residual paralysis after a single intubating dose of rocuronium: an unexpected cause]. / Bloc résiduel prolongé après injection unique de rocuronium pour l'intubation : une étiologie originale.

Postoperative curarization following a single dose of rocuronium is a known risk quickly diagnosed through the monitoring of neuromuscular blockade. Different etiologies can cause a prolonged block. We report the case of a misdiagnosis of prolonged neuromuscular blockade by a failure in the monitoring system of curarization.

[Fast recovery of haemodynamic and ventilatory functions after sugammadex bolus following rocuronium-induced anaphylactic shock refractory to conventional treatment]. / Récupération hémodynamique et ventilatoire rapide après injection de sugammadex lors d'un choc anaphylactique au rocuronium, réfractaire au traitement conventionnel.

Recently, three case reports have suggested the possible efficacy of sugammadex in anaphylactic shock refractory to conventional treatment induced by rocuronium. We report a new case of severe anaphylactic reaction to rocuronium treated with sugammadex. After 18 minutes of conventional treatment because of persistent cardiocirculatory failure and bronchospasm, a bolus of 2000 mg (18 mg/kg) of sugammadex was injected. This was associated with rapid correction of arterial hypotension and bronchoconstriction. The underlying pathophysiological mechanisms that explain the potential beneficial effect of sugammadex in this context are unknown but it is important to know that refractory anaphylactic shock to rocuronium can be potentially corrected with sugammadex.

[Clinical evaluation of post-surgical bleeding after a sugammadex injection]. / Évaluation clinique du saignement post-chirurgical après injection de sugammadex.

OBJECTIVE: Sugammadex reverses neuromuscular blockade by chemical encapsulation of nondepolarizing neuromuscular blocking drugs (rocuronium and vecuronium). The imprint of this new molecule has recently been supplemented with a section on haemostasis notifying a longer clotting time without documented clinical consequences. This has resulted in recommendations on the use of sugammadex in the presence of coagulation disorders (pharmacologically-induced or not). The objective of this study was to analyze the experience gathered with this molecule on clinically-evaluated bleeding. No study on this subject is currently available. METHODS: This is a retrospective study over 1 year between August 2009 and August 2010. All patients with laparotomies for cancer surgery requiring suction drains were included. Patients were allocated to groups according to the type of reversal (without sugammadex versus sugammadex 2 or 4 mg/kg). The endpoint was clinically-evaluated postoperative bleeding (reoperation for haemostasis, blood-stained laparotomy dressings in the post-anaesthesia care unit [PACU], cumulative volume collected in suction drains upon arrival in PACU and then after 2 hours and the next morning at 6a.m). RESULTS: One hundred and ninety-three patients were included in three groups, 78 in the group "without sugammadex", 95 in "sugammadex 2mg/kg" and 20 in "sugammadex 4 mg/kg". There were no reoperations for haemostasis. The comparison among different groups for the endpoint of bleeding showed no significant difference. CONCLUSION: In this retrospective study performed in patients at high risk of postoperative bleeding, sugammadex at doses of 2 and 4 mg/kg was not associated with increased bleeding. This study, the first in this field, suggests that future prospective investigations should target patients receiving 4 or 16 mg/kg of sugammadex and/or with documented preoperative abnormal coagulations tests.

[Perioperative anaesthetic management of an epileptic patient treated with a vagus nerve stimulation]. / Gestion périopératoire d'un patient épileptique porteur d'une neurostimulation du nerf vague.

The vagal nerve stimulation is approved for medically refractory epilepsy and major depression. We report the perioperative management of an epileptic patient with this indwelling device. This observation summarizes the physiologic implications and the specific anaesthetic considerations for procedures with this pre-existing device.

[Impact of the hyperthermic intraperitoneal chemotherapy on the fluid-electrolytes changes and on the acid-base balance]. / Retentissements hydroélectrolytiques et acidobasiques de la chimiohyperthermie intrapéritonéale.

BACKGROUND: Hyperthermic intraperitoneal chemoperfusion (HIPEC) is an innovative treatment of the peritoneal carcinomatosis with potential iatrogenicity. This observational study was designed to improve our understanding of HIPEC's impact on the renal and respiratory functions, on temperature, blood cells counts, body fluids/electrolytes and acid-base balance. METHODS: We retrospectively analyzed the perioperative care of 20 patients that underwent HIPEC with oxaliplatin (n=19) and mitomycin C (n=1). The abdominal cavity was filled with the peritoneal dialysis fluid with dextrose 5%: volume of 2L/m(2). Follow-up for the study was stopped on postoperative day 7. RESULTS: The main changes were appearing just after the HIPEC procedure: increased diuresis, lactic acidosis, hyponatremia and hyperglycaemia (despite aggressive intravenous insulin therapy). In our series, there was no renal failure or impact on blood cells counts until the 7(th) day, neither some changes on the arterial blood gases. CONCLUSION: Hyperglycemia might explain increased diuresis of lactic acidosis and the rapid installation of hyponatremia. Taken together, these results suggest that glycemic control must be improved in order to avoid the other metabolic disturbances.