Developing expert international consensus statements for opioid-sparing analgesia using the Delphi method.

INTRODUCTION: The management of postoperative pain in anaesthesia is evolving with a deeper understanding of associating multiple modalities and analgesic medications. However, the motivations and barriers regarding the adoption of opioid-sparing analgesia are not well known. METHODS: We designed a modified Delphi survey to explore the perspectives and opinions of expert panellists with regard to opioid-sparing multimodal analgesia. 29 anaesthetists underwent an evolving three-round questionnaire to determine the level of agreement on certain aspects of multimodal analgesia, with the last round deciding if each statement was a priority. RESULTS: The results were aggregated and a consensus, defined as achievement of over 75% on the Likert scale, was reached for five out of eight statements. The panellists agreed there was a strong body of evidence supporting opioid-sparing multimodal analgesia. However, there existed multiple barriers to widespread adoption, foremost the lack of training and education, as well as the reluctance to change existing practices. Practical issues such as cost effectiveness, increased workload, or the lack of supply of anaesthetic agents were not perceived to be as critical in preventing adoption. CONCLUSION: Thus, a focus on developing specific guidelines for multimodal analgesia and addressing gaps in education may improve the adoption of opioid-sparing analgesia.

Chronic post-surgical pain after colon surgery in patients included in an enhanced recovery program.

BACKGROUND: Enhanced recovery after surgery (ERAS) program improves immediate recovery. Beyond immediate benefits, long-term impact of ERAS implementation is not yet evident. This retrospective single-center cohort study investigates prevalence and characteristics of chronic post-surgical pain (CPSP) in patients who underwent colon surgery. METHODS: Two hundred and ninety-seven patients enrolled prospectively in our ERAS database were contacted by mail to question the presence of CPSP. In case of CPSP, intensity, location, and type of pain, impact of pain on quality of life and treatment taken were assessed. Post-operative pain experience during hospital stay, recall of pain, and discomfort duration when back home were assessed in all patients. Comparison between patients with and without CPSP was made to approach the risk factors of CPSP in this population. RESULTS: At 27 months after colon surgery, 25/198 patients reported CPSP (12.6%) and pain was severe in 5 patients (2.5%). CPSP had a deep abdominal component in 56% of patients and a parietal component in 20% of patients. Patients with CPSP+ differed from patients CPSP- for pre-operative pain presence (56% vs 24.8%, P = 0.004), recalled post-operative pain intensity (4 vs 3, P = 0.045), duration of discomfort after discharge (2 vs 1 weeks, P = 0.035). Pre-operative pain was found as a significant CPSP risk factor (odds ratio 1.34; 95% CI: 1.05-1.70). CONCLUSION: CPSP prevalence after laparoscopic colon surgery seems not much affected by ERAS context. Pre-operative presence of pain emerged as an important risk factor. These findings should be confirmed in a prospective multicenter study.

The 2024 French guidelines for scenario design in simulation-based education: manikin-based immersive simulation, simulated participant-based immersive simulation and procedural simulation.

BACKGROUND: Simulation-based education in healthcare encompasses a wide array of modalities aimed at providing realistic clinical experiences supported by meticulously designed scenarios. The French-speaking Society for Simulation in Healthcare (SoFraSimS) has developed guidelines to assist educators in the design of scenarios for manikin- or simulated participant- based immersive simulation and procedural simulation, the three mainly used modalities. METHODS: After establishing a French-speaking group of experts within the SoFraSimS network, we performed an extensive literature review with theory-informed practices and personal experiences. We used this approach identify the essential criteria for practice-based scenario design within the three simulation modalities. RESULTS: We present three comprehensive templates for creating innovative scenarios and simulation sessions, each tailored to the specific characteristics of a simulation modality. The SoFraSimS templates include five sections distributed between the three modalities. The first section contextualizes the scenario by describing the practicalities of the setting, the instructors and learners, and its connection to the educational program. The second section outlines the learning objectives. The third lists all the elements necessary during the preparation phase, describing the educational method used for procedural simulation (such as demonstration, discovery, mastery learning, and deliberate practice). The fourth section addresses the simulation phase, detailing the behaviors the instructor aims to analyze, the embedded triggers, and the anticipated impact on simulation proceedings (natural feedback). This ensures maximum control over the learning experience. Finally, the fifth section compiles elements for post-simulation modifications to enhance future iterations. CONCLUSION: We trust that these guidelines will prove valuable to educators seeking to implement simulation-based education and contribute to the standardization of scenarios for healthcare students and professionals. This standardization aims to facilitate communication, comparison of practices and collaboration across different learning and healthcare institutions.

'What this article adds'1. The SoFraSimS provides guidelines to facilitate the development of simulation-based activities.2. These guidelines are theory-informed as well as evidence and experience-based.3. A detailed approach to writing a complete activity or scenario for procedural and immersive simulation including manikins or simulated participants is provided (the 'SoFraSimS templates').4. This work aims at standardizing practices and exchanging scenarios between simulation centers.

Expert Multinational Consensus Statement for Total Intravenous Anaesthesia (TIVA) Using the Delphi Method.

Introduction: The use of total intravenous anaesthesia (TIVA) has been well established as an anaesthetic technique over the last few decades. Significant variation in practice exists however, and volatile agents are still commonly used. This study aims to determine the motivations and barriers for using TIVA over the use of volatile agents by analysing the opinion of several international anaesthetists with specific expertise or interests. Methods and participants: The Delphi method was used to gain the opinions of expert panellists with a range of anaesthetic subspecialty expertise. Twenty-nine panellists were invited to complete three survey rounds containing statements regarding the use of TIVA. Anonymised data were captured through the software REDCap and analysed for consensus and prioritisation across statements. Starting with 12 statements, strong consensus was defined as ≥75% agreement. Stability was assessed between rounds. Results: Strong consensus was achieved for four statements regarding considerations for the use of TIVA. These statements addressed whether TIVA is useful in paediatric anaesthesia, the importance of TIVA in reducing the incidence of postoperative nausea and vomiting, its positive impact on the environment and effect on patient physiology, such as airway and haemodynamic control. Conclusions: Using the Delphi method, this international consensus showed that cost, lack of familiarity or training and the risk of delayed emergence are not considered obstacles to TIVA use. It appears, instead, that the primary motivations for its adoption are the impact of TIVA on patient experience, especially in paediatrics, and the benefit to the overall procedure outcome. The effect of TIVA on postoperative nausea and vomiting and patient physiology, as well as improving its availability in paediatrics were considered as priorities. We also identified areas where the debate remains open, generating new research questions on geographical variation and the potential impact of local availability of monitoring equipment.

Simulation-based summative assessment in healthcare: an overview of key principles for practice.

BACKGROUND: Healthcare curricula need summative assessments relevant to and representative of clinical situations to best select and train learners. Simulation provides multiple benefits with a growing literature base proving its utility for training in a formative context. Advancing to the next step, "the use of simulation for summative assessment" requires rigorous and evidence-based development because any summative assessment is high stakes for participants, trainers, and programs. The first step of this process is to identify the baseline from which we can start. METHODS: First, using a modified nominal group technique, a task force of 34 panelists defined topics to clarify the why, how, what, when, and who for using simulation-based summative assessment (SBSA). Second, each topic was explored by a group of panelists based on state-of-the-art literature reviews technique with a snowball method to identify further references. Our goal was to identify current knowledge and potential recommendations for future directions. Results were cross-checked among groups and reviewed by an independent expert committee. RESULTS: Seven topics were selected by the task force: "What can be assessed in simulation?", "Assessment tools for SBSA", "Consequences of undergoing the SBSA process", "Scenarios for SBSA", "Debriefing, video, and research for SBSA", "Trainers for SBSA", and "Implementation of SBSA in healthcare". Together, these seven explorations provide an overview of what is known and can be done with relative certainty, and what is unknown and probably needs further investigation. Based on this work, we highlighted the trustworthiness of different summative assessment-related conclusions, the remaining important problems and questions, and their consequences for participants and institutions of how SBSA is conducted. CONCLUSION: Our results identified among the seven topics one area with robust evidence in the literature ("What can be assessed in simulation?"), three areas with evidence that require guidance by expert opinion ("Assessment tools for SBSA", "Scenarios for SBSA", "Implementation of SBSA in healthcare"), and three areas with weak or emerging evidence ("Consequences of undergoing the SBSA process", "Debriefing for SBSA", "Trainers for SBSA"). Using SBSA holds much promise, with increasing demand for this application. Due to the important stakes involved, it must be rigorously conducted and supervised. Guidelines for good practice should be formalized to help with conduct and implementation. We believe this baseline can direct future investigation and the development of guidelines.

Is Intraoperative Opioids Avoidance A Utopia? A Matched Study in Laparoscopic Hysterectomy.

BACKGROUND: Opioid-sparing strategies are recommended, and Opioid-Free Anaesthesia (OFA) is proposed in the literature. But few data exist about the feasibility of OFA in the routine practice. From a larger series of 21,463 patients receiving OFA, this work investigates the postoperative pain and related outcomes in patients undergoing laparoscopic hysterectomy. MATERIALS AND METHODS: This matched retrospective study concerned 521 patients scheduled for a laparoscopic hysterectomy between 2010 and 2015 (118 receiving OFA and 403 receiving anaesthesia with opioids, AO). Primary outcome was pain in the Post-Anaesthetic Care Unit (PACU). RESULTS: Among the 521 included patients, 403 received sufentanil (mean±SD: 0.1±0.05 mcg/kg), the only synthetic opioid used to balance anaesthesia. Concerning the 118 patients receiving OFA, most of them received an association of clonidine (97%) and ketamine (95%). Most of the patients in both groups received non-steroidal anti-inflammatory drugs. No difference in pain scores was observed between AO and OFA (median [IQR], respectively: 4 [0-5] vs. 4.5 [0-6], P=0.74). A difference in the perioperative morphine equivalent use was observed (mean±SD: 0.18±0.06 mg/kg vs. 0.09±0.06 mg/kg, P<0.001). No difference was observed regarding the nausea/vomiting incidences, use of anti-emetics, sedation scores, or time spent at the PACU. CONCLUSION: Coming from an extensive daily practice, these data show that OFA is feasible and not associated with higher pain scores or longer PACU stay, suggesting the absence of specific immediate complications.

In situ simulation improves perceived self-efficacy of OR nurses and anaesthesiologists during COVID-19 pandemic.

Introduction: Self-efficacy is defined as people's internal beliefs about their ability to have an impact on events that affect their lives. As part of the COVID-19 pandemic, we carried out in situ simulation for anaesthesiologists and operating room (OR) nurses. Simulation was focused on the recommendations on the use of specific personal protective equipment (PPE) as well as on airway management and intubation. We hypothesised that in situ procedural simulation should increase their perceived self-efficacy. Methods: Between 16 March and 20 March 2020, 208 healthcare workers took part in in situ procedural simulation. A questionnaire was sent to participants on 21 April 2020. Six self-efficacy items related to PPE and airway manoeuvres were assessed before and after training on a Numeric Rating Scale from 0 to 10. Results: Sixty-seven participants (32%) replied to the questionnaire. The before-after comparison of the six items revealed an increase in perceived self-efficacy for each of them. A before training difference was observed between nurses, board-certified anaesthetists and trainees in anaesthesia in perceived self-efficacy for putting on (6 (3-8) vs 4.5 (2.25-6) vs 2 (0-6), p=0.007) and remove PPE (8 (5-8) vs 4.5 (3.25-6) vs 4 (1-6), p=0.009). No difference in perceived self-efficacy after training was observed between nurses, board-certified anaesthetists and trainees in anaesthesia. Conclusions: In situ simulation improves the perceived self-efficacy of OR nurses and anaesthesiologists on specific skills related to the care of patients with COVID-19.

Anesthetic Management of a Child With Rapid-Onset Dystonia-Parkinsonism (DYT12-ATP1A3): A Case Report.

Rapid-onset dystonia-parkinsonism also known as DYT12-ATP1A3 is an extremely rare neurological disease. Patients develop dystonia, bradykinesia, postural instability, dysarthria, and dysphagia. Injection of botulinum toxin is the first-choice treatment for focal dystonia. We report the case of a 14-year-old patient diagnosed with rapid-onset dystonia-parkinsonism who was scheduled for injection of botulinum toxin in his upper limbs under general anesthesia. To our knowledge, there is no previous report about the anesthetic management of patients with rapid-onset dystonia-parkinsonism.

Goal-directed fluid management based on the pulse oximeter-derived pleth variability index reduces lactate levels and improves fluid management.

BACKGROUND: Dynamic variables predict fluid responsiveness and may improve fluid management during surgery. We investigated whether displaying the variability in the pulse oximeter plethysmogram (pleth variability index; PVI) would guide intraoperative fluid management and improve circulation as assessed by lactate levels. METHODS: Eighty-two patients scheduled for major abdominal surgery were randomized into 2 groups to compare intraoperative PVI-directed fluid management (PVI group) versus standard care (control group). After the induction of general anesthesia, the PVI group received a 500-mL crystalloid bolus and a crystalloid infusion of 2 mL · kg(-1) · h(-1). Colloids of 250 mL were administered if the PVI was >13% Vasoactive drug support was given to maintain the mean arterial blood pressure above 65 mm Hg. In the control group, an infusion of 500 mL of crystalloids was followed by fluid management on the basis of fluid challenges and their effects on mean arterial blood and central venous pressure. Perioperative lactate levels, hemodynamic data, and postoperative complications were recorded prospectively. RESULTS: Intraoperative crystalloids and total volume infused were significantly lower in the goal-directed PVI group. Lactate levels were significantly lower in the PVI group during surgery and 48 hours after surgery (P < 0.05). CONCLUSIONS: PVI-based goal-directed fluid management reduced the volume of intraoperative fluid infused and reduced intraoperative and postoperative lactate levels.

Short message service as a tool to improve perioperative follow-up of surgical outpatients: A before-after study.

BACKGROUND: In outpatient surgery, the patients may be called by phone for detecting and managing perioperative problems. However, phone calls consume time and can waste caregiver's time when the patient is not available. Information and communication technologies could bridge the gap between available resources and need to contact patients. METHODS: In the present before-after study, the before-implementation group was contacted by phone (phone group). The after group was contacted with a SMS or a phone call according to patient's preference (SMS group). The primary outcome was the non-inferiority of the SMS system on the occurrence of preoperative events disturbing the organisation of unit including cancellation of the case related to patient's condition the day before and the day of surgery; non-compliance with fasting rules or requirement of an escort; non-adherence to instructions regarding medication; not reporting to the surgical centre, or a delayed arrival > 30 min. RESULTS: Among 1300 included outpatients (650 per group), 381 (59%) and 542 (83%) patients were successfully contacted in the preoperative period in phone or SMS group, respectively P < 0.0001). Preoperative events were observed in 94 patients of the phone group (14.5% [CI 95% 11.9-17.3]) and in 77 patients of the SMS group (11.8% [CI 95% 9.5-14.6]), meaning that the upper bound 95% CI of the group was within the non-inferiority margin. CONCLUSIONS: In outpatient surgery, implementation of an SMS-based system, supplemented by phone calls for contacting patients is not inferior to a phone-based system in regard to preoperative events.

Something new about ketamine for pediatric anesthesia?

PURPOSE OF REVIEW: This review discusses the place of the old anesthetic ketamine in pediatric anesthesia. RECENT FINDINGS: Despite the availability of modern alternatives, ketamine remains a frequently used drug particularly for anesthesia in high-risk children and for procedures outside the operating room. In adult patients undergoing surgery, a renewed interest in this drug is noted. It is the consequence of recent demonstrations of the following effects. First, ketamine is highly effective against surgery and opiate-induced hyperalgesia. Second, it has original antiproinflammatory properties. In other words, it promotes self-limitation of the inflammatory response that follows surgery. In the pediatric population, these benefits wait to be confirmed. Finally, questions arise about the safety of ketamine anesthesia. Ketamine is a potent proapoptotic drug. In rodents treated during the critical period for central nervous system development, long-term behavioral deficits were noted after an anesthetic dose of ketamine. The exact consequences of these proapoptotic properties on human brain tissue development have to be exactly determined and are still debatable. SUMMARY: Ketamine has not yet revealed all its interactions in humans. Recent discoveries indicate interesting properties on the one hand and potentially deleterious effects on the other.

Pain management in living related adult donor hepatectomy: feasibility of an evidence-based protocol in 100 consecutive donors.

OBJECTIVE: Living donor hepatectomy (LDH) has important consequences in terms of acute and chronic pain. We proposed an anesthetic protocol based on the best currently available evidence. We report the results of this protocol's application. RESULTS: We performed a retrospective descriptive study of 100 consecutive donors undergoing LDH. The protocol included standardized information provided by the anesthetist, pharmacological anxiolysis and preventive analgesia. Specifically, pregabalin premedication (opioid-free) intravenous anesthesia (with clonidine, ketamine, magnesium sulphate and ketorolac) and epidural analgesia were proposed. Postoperative follow-up was conducted by the Postoperative Pain Service. This analysis included 100 patients (53 women, 47 men, median age 32.7 years old [28.4-37.3]), operated by xypho-umbilical laparotomy. All elements of our anesthetic protocol were applied in over 75% of patients, except for the preoperative consultation with a senior anesthesiologist (55%). The median number of applied item was 7 [interquartile range, IQR 5-7]. Median postoperative pain scores were, at rest and at mobilization respectively 3 [IQR 2-4] and 6 [IQR 4.5-7] on day 1; 2 [IQR 1-3] and 5 [IQR 3-6] on day 2; and 2 [IQR 0-3] and 4 [IQR 3-5] on day 3. In conclusion, LDH leads to severe acute pain. Despite the proposal of a multimodal evidence-based protocol, its applicancy was not uniform and the pain scores remained relatively high.

Prolonged unconsciousness in a patient on automated peritoneal dialysis.

A 79-year-old man with end-stage renal disease treated by automated peritoneal dialysis was referred to the emergency department for altered consciousness. The first investigations, including toxicology screening, failed to reveal the precise etiology. The patient was treated for a possible seizure. After the progression of central nervous system depression with bradypnea, the patient was intubated and mechanically ventilated. It appeared later on that he had ingested by mistake one of his wife's medications, baclofen. Baclofen was detected in the blood sampled on admission at a level above the therapeutic range. Baclofen is mainly excreted by the kidney. A short-term administration of low-dose of baclofen is not effectively removed by peritoneal dialysis and may result in prolonged but reversible coma.

The concept of titration can be transposed to fluid management. but does is change the volumes? randomised trial on pleth variability index during fast-track colonic surgery.

BACKGROUND: The concept of drug titration emerged recently for intraoperative fluid administration during Fast-Track colonic surgery to avoid hypovolemia as well as excessive crystalloid administration. The Pleth Variability Index (PVI) is an oximeter-derived parameter. It allows a continuous monitoring of the respiratory variation of the perfusion index. OBJECTIVE: To investigate if applying the concept of fluid titration with PVI-guided colloid administration conjointly with restricted crystalloids administration changes the amount of fluid administered. DESIGN, SETTINGS AND PATIENTS: Twenty one ASA 2 patients scheduled for Fast-Track colonic surgery were randomized in two groups: the PVI-guided the fluid management group and the the control group. INTERVENTION AND MAIN OUTCOME MEASURES: After the induction of general anesthesia, the PVI group received a 10 mL.kg- 1.h-1 infusion of crystalloid during the first hour, reduced to 2 mL.kg-1.h-1 thereafter. Colloids 250 mL were administered if necessary to maintain a PVI value of 10 to 13%. In the control group, a 10 mL.kg-1.h-1 infusion of crystalloid during the first hour was followed by a 5 mL.kg-1.h-1 infusion. Boluses of 250 mL of colloids were administered if required to maintain the mean arterial pressure above 65 mmHg. RESULTS: Intraoperative crystalloids infused volume were significantly lower in the PVI group (925+/-262 mL vs 1129+/- 160 mL; P=0.04). In contrast, the infused amounts of colloids was higher in the PVI group (725+/-521 mL vs 250+/-224 mL; P=0.01). Interestingly, total fluid amount infused intra- ant postoperatively were similar between the groups (1650+/- 807 mL vs 1379+/-186 mL; P=0.21). CONCLUSION: PVI-guided fluid management in Fast-Track colonic surgery is not necessarily associated with different total volume infused.