Protocol of supra-visceral aortic ischemic preconditioning for open surgical repair of thoracoabdominal aortic aneurysm : The EPICATA study (Evaluation of the Efficacy of Ischemic PreConditioning on morbidity and mortality in open ThoracoAbdominal Aortic surgery).

BACKGROUND: Open surgical repair (OSR) for thoracoabdominal aortic aneurysms (TAA) is associated with a high pulmonary and renal morbidity rate. Ischemic preconditioning (IPC) is a mechanism of protection against the deleterious effects of ischemia-reperfusion. To our knowledge IPC has never been tested during OSR for TAA. METHODS: The primary objective of the study is to evaluate the efficacy of IPC during OSR for TAA with respect to acute kidney injury (AKI) according to KDIGO and pneumonia/prolonged ventilation-time during the first 8 postoperative days. The secondary objectives are to compare both arms with respect to cardiac complications within 48 h, renal and pulmonary complications within 21 days and mortality at 60 days. To assess the efficacy of IPC with respect to pulmonary and renal morbidity, a cox model for competing risks will be used. Assuming that the event occurs among 36% of the patients when no IPC is performed, the allocation of 55 patients to each arm should allow detecting a hazard ratio of at least 2.75 with a power of 80% when admitting 5% for an error of first kind. This means that 110 patients, enrolled in this multicenter study, may be randomised within 36 months of the first randomization. Randomization will be performed to allocate patients either to surgery with preconditioning before aortic cross clamping (Arm 1) or to surgery without preconditioning before aortic cross clamping (Arm 2). Randomization takes place during the intervention after intravenous injection of heparin, or after the start of femoral assistance. The procedure for IPC will be a supra-visceral thoracic aortic cross clamping for 5 min followed by an unclamping period of 5 min. This procedure will be repeated twice before starting thoracic aortic cross clamping needed to perform surgery. CONCLUSIONS: Our hypothesis is that ischemic preconditioning could reduce clinical morbidity and the incidence of lung damage associated with supra-visceral aortic clamping. TRIAL REGISTRATION: EPICATAStudy registered in ClinicalTrial.gov / number: NCT03718312 on Oct.24.2018 URL number.

Passive Temporary Visceral Shunt from the Axillar Artery as an Adjunct Method during the Open Treatment of Thoracoabdominal Aortic Aneurysm.

BACKGROUND: Distal aortic retrograde perfusion systems like the left heart bypass or femoro-femoral extracorporeal circulation are the methods of reference for organ protection during direct approaches to thoracoabdominal aortic aneurysms. The aim of this work was to evaluate the use of a passive arterial shunt to reduce visceral ischemia during aortic operations when occlusive diseases of the iliac arteries make distal aortic retrograde perfusion inappropriate. METHODS: Ten patients affected by a Crawford type III thoracoabdominal aneurysm (TAA) were operated on between January 2013 and January 2015 with the use of a temporary shunt inserted onto the left axillar artery that allows visceral perfusion immediately after the aorta is opened. The operation was performed after a single dose of heparin (50 UI/kg). The sera lactate levels were measured 2 hr after the last aortic clamp was removed and compared with those obtained from a group of 19 patients operated on for a Crawford type IV TAA during the same period without any arterial shunt. RESULTS: Neither mortality nor paraplegia occurred. The sera lactate levels were lower in the group of patients operated on for a type III TAA (2.57 ± 1) than for a type IV TAA (3.68 ± 1) (P < 0.01, Student's t-test). CONCLUSION: This method was effective for low mesenteric ischemia, easy to perform, and did not require high doses of anticoagulants.

Erector Spinae Plane Block versus Paravertebral Block after Thoracic Surgery for Lung Cancer: A Propensity Score Study.

INTRODUCTION: The prevention of respiratory complications is a major issue after thoracic surgery for lung cancer, and requires adequate post-operative pain management. The erector spinae plane block (ESPB) may decrease post-operative pain. The objective of this study was to evaluate the impact of ESPB on pain after video or robot-assisted thoracic surgery (VATS or RATS). METHODS: The main outcome of this retrospective study with a propensity score analysis (PSA) was to compare the post-operative pain at 24 h at rest and at cough between a group that received ESPB and a group that received paravertebral block (PVB). Post-operative morphine consumption at 24 h and complications were also assessed. RESULTS: One hundred and seven patients were included: 54 in the ESPB group and 53 in the PVB group. The post-operative median pain score at rest and cough was lower in the ESPB group compared to the PVB group at 24 h (respectively, at rest 2 [1; 3.5] vs. 2 [0; 4], p = 0.0181, with PSA; ESPB -0.80 [-1.50; -0.10], p = 0.0255, and at cough (4 [3; 6] vs. 5 [4; 6], p = 0.0261, with PSA; ESPB -1.48 [-2.65; -0.31], p = 0.0135). There were no differences between groups concerning post-operative morphine consumption at 24 h and respiratory complications. CONCLUSIONS: Our results suggest that ESPB is associated with less post-operative pain at 24 h than PVB after VATS or RATS for lung cancer. Furthermore, ESPB is an acceptable and safe alternative compared to PVB.

Paravertebral block combined with serratus anterior plane block after video-assisted thoracic surgery: a prospective randomized controlled trial.

OBJECTIVES: Adequate pain management after thoracoscopic surgery is a major issue in the prevention of respiratory complications. The combination of the paravertebral block (PVB) with the serratus anterior plane block (SAPB) may decrease postoperative pain. The objective of this study was to evaluate the impact of the combination of PVB and SAPB on the consumption of morphine and pain after video- or robot-assisted thoracic surgery. METHODS: The main objective of this randomized controlled trial was to compare the cumulative postoperative morphine consumption at 24 h between a group having PVB (PVB group) and a group having PVB and SAPB (PV-SAPB group). Postoperative pain at 6 and 24 h and morphine-related complications were also assessed. RESULTS: A total of 112 patients were included with 56 in each group. There was no difference in median cumulative morphine consumption at 24 h between the 2 groups (P = 0.1640). At 6 h, the median postoperative pain was higher in the PVB group compared to the PV-SAPB group (3 [0; 4] vs 2 [0; 3], P = 0.0231). There were no differences between the 2 groups for pain at 24 h and morphine-related complications. CONCLUSIONS: We did not find any difference in morphine consumption between the 2 groups. Our results suggest that the combination of PVB and SAPB for video-assisted thoracic surgery or robot-assisted thoracic surgery is safe effective and reliable and could be an alternative to PVB alone in certain indications.

Impact of Opioid-free Anesthesia After Video-assisted Thoracic Surgery: A Propensity Score Study.

BACKGROUND: Adequate postoperative morphine consumption and pain management after thoracic surgery are major issues in the prevention of respiratory complications. Opioid-free anesthesia (OFA) may decrease morphine consumption and postoperative pain. The objective of this study was to evaluate the impact of OFA on the consumption of morphine and pain after video-assisted thoracic surgery or robotic-assisted thoracic surgery. METHODS: The main objective of this retrospective study with propensity score analysis (PSA) was to compare the cumulative postoperative morphine consumption at 48 hours between an OFA group receiving dexmedetomidine, lidocaine, and ketamine; and an opioid anesthesia (OA) group receiving remifentanil plus morphine. Postoperative pain at 24 and 48 hours and respiratory and hemodynamics complications were also assessed. RESULTS: Eighty-one patients were included, 48 in the OFA group and 33 in the OA group. The cumulative postoperative morphine consumption at 48 hours was lower in the OFA group than in the OA group (28.5 mg [0 to 62.25 mg] vs 55 mg [34 to 79.5 mg], P = .002, with PSA; OFA -27.67 mg [-46 mg to -11.5 mg], P = .002). The postoperative pain score was significantly lower in the OFA group compared with the OA group at 24 hours (2 [0 to 4] vs 3 [2 to 5], P = .064, with PSA; OFA -1.40 [-2.47 to -0.33], P = .0088) and 48 hours (0 [0 to 3] vs 2.5 [0 to 5], P = .034, with PSA; OFA -1.87 [-3.45 to -0.28], P = .021). There were no differences between groups concerning respiratory or hemodynamic complications. CONCLUSIONS: Our results suggest that OFA after video-assisted thoracic surgery or robotic-assisted thoracic surgery is safe and is associated with less postoperative morphine cumulative consumption and pain at 48 hours.

Skeletal muscle mass and adipose tissue alteration in critically ill patients.

BACKGROUND: Increasing numbers of studies in chronic diseases have been published showing the relationship between body composition (BC) parameters (i.e. skeletal muscle mass (SMM) and adipose tissue (AT)) and outcomes. For patients admitted to intensive care unit (ICU), BC parameters have rarely been described as a prognostic marker of outcome. The primary objective was to evaluate the relationship between body composition at ICU admission and major clinical outcomes. Secondary objectives were to assess the relationship between BC parameters and other parameters (systemic inflammatory markers, Sequential Organ Failure Assessment (SOFA) score, albumin level) at ICU admission, and between BC alterations during ICU stay and outcomes. PATIENTS AND METHODS: This retrospective study enrolled 25 adult patients who had two abdominal CT scans for clinical indication: first, within 48 hours of ICU admission (initial assessment), and second, 7 to 14 days later (late assessment). Skeletal Muscle radiodensity (SMD), cross-sectional area of SMM, Visceral Adipose Tissue (VAT) and Subcutaneous Adipose Tissue (SAT) were measured at the third lumbar vertebra. Cox regression analysis was used to determine the association between these parameters and mortality. RESULTS: Patients' mean age was 64.6 years. Their mean BMI was 27.7 kg/m2 (SD = 6.0). ICU mortality was 36%. There was no correlation between BC parameters at initial assessment and ICU outcomes. We observed a negative correlation between SMM index and SOFA score at initial assessment (r = -0.458, p = 0.037). There was a significant loss of VAT between two CT assessments which was associated with mortality (-22.34cm2 / m2 in non-survivors versus -6.22 cm2 / m2 in survivors, p = 0.039). Loss of SMD was greater with the occurrence of an infection than without (Delta SMD = -5.642 vs +1.957, p = 0.04). CONCLUSIONS: Our results show alterations in body composition during ICU stay with a loss of muscle quality (decreased SMD) and adipose tissue. These findings require confirmation in future studies but already show that BC assessments at ICU admission and BC alterations during ICU stay are important factors for outcome in critically ill patients.