Effect of a comfort scale compared with a pain numerical rate scale on opioids consumption in postanaesthesia care unit: the COMFORT study.

BACKGROUND: The way that pain is assessed in the PACU could impact on postoperative pain and analgesic consumption. However, there is currently no evidence to support this speculation. The authors hypothesised that using a comfort scale reduces postoperative opioid consumption when compared with a standard numerical rating scale (NRS) to evaluate pain in the PACU. METHODS: In this cluster-randomised trial, patients were assessed using either a comfort scale (comfort group) or a pain NRS (NRS group). The primary outcome was the opioid consumption in the PACU. The main secondary outcomes were postoperative pain, nausea and vomiting, length of stay in the PACU, and satisfaction. RESULTS: Of 885 randomised patients, 860 were included in the analysis. Opioid consumption in the PACU was comparable in the comfort and NRS groups (median [interquartile range [IQR] 0 (0-5) vs 0 (0-6); P=0.2436), irrespective of the type of surgical procedure. The majority of patients did not need any postoperative opioid (59% in the comfort group and 56% in the NRS group, P=0.2260). There was no difference in postoperative pain, nausea and vomiting, time to reach an Aldrete score ≥9 after extubation, and global satisfaction. CONCLUSIONS: Using a comfort scale to assess pain in the PACU did not spare any opioid compared with use of a standard NRS. Further studies focusing on patients at risk of increased postoperative opioid consumption are necessary. CLINICAL TRIAL REGISTRATION: NCT05234216.

Relationship Between Preoperative Inflammation Ratios Derived From Preoperative Blood Cell Count and Postoperative Pulmonary Complications in Patients Undergoing Lobectomy: A Single-Center Observational Study.

OBJECTIVE: Evaluation of the association of inflammatory cell ratios, especially neutrophil-to-lymphocyte ratio (NLR), based on preoperative complete blood counts, with postoperative complications in lobectomy surgery. DESIGN: This was a retrospective monocentric cohort study. SETTING: The study was conducted at Foch University Hospital in Suresnes, France. PARTICIPANTS: Patients having undergone a scheduled lobectomy from January 2018 to September 2021. INTERVENTIONS: There were no interventions. MEASUREMENTS AND MAIN RESULTS: The authors studied 208 consecutive patients. Preoperative NLR, monocyte-to-lymphocyte ratio, platelet-to-lymphocyte ratio, systemic inflammation index, systemic inflammation response index, and aggregate inflammation systemic index were calculated. Median and (IQR) of NLR was 2.67 (1.92-3.69). No statistically significant association was observed between any index and the occurrence of at least one major postoperative complication, which occurred in 37% of the patients. Median postoperative length of stay was 7 (5-10) days. None of the ratios was associated with prolonged length of stay (LOS), defined as a LOS above the 75th percentile. CONCLUSIONS: The results suggested that simple available inflammatory ratios are not useful for the preoperative identification of patients at risk of postoperative major complications in elective lobectomy surgery.

Results of Lung Transplantation for Cystic Fibrosis With Selected Donors Over 65 Years Old.

Lung transplantation is limited by the shortage of suitable donors. Many programs have begun to use extended criteria donors. Donors over 65 years old are rarely reported, especially for young cystic fibrosis recipients. This monocentric study was conducted for cystic fibrosis recipients from January 2005 to December 2019, comparing two cohorts according to lung donor age (<65 years or ≥65 years). The primary objective was to assess the survival rate at 3 years using a Cox multivariable model. Of the 356 lung recipients, 326 had donors under 65 years, and 30 had donors over 65 years. Donors' characteristics did not differ significantly in terms of sex, time on mechanical ventilation before retrieval, and partial pressure of arterial oxygen/fraction of inspired oxygen ratio. There were no significant differences in post-operative mechanical ventilation duration and incidence of grade 3 primary graft dysfunction between the two groups. At 1, 3, and 5 years, the percentage of predicted forced expiratory volume in 1 s (p = 0.767) and survival rate did not differ between groups (p = 0.924). The use of lungs from donors over 65 years for cystic fibrosis recipients allows extension of the donor pool without compromising results. Longer follow-up is needed to assess the long-term effects of this practice.

How We Would Treat Our Own Lung Transplantation: A Multidisciplinary and International Perspective.

Lung transplantation is the ultimate treatment for end-stage lung disease (ESLD) arising from various etiologies. This manuscript will focus on selected aspects of a theoretical perioperative lung transplantation plan, highlighting data-driven and theoretical techniques the authors would employ if they were the index patient undergoing surgery. Beginning with looking for a transplant center using an Internet search, patient advocacy organizations, and artificial intelligence guidance, the authors lay out a course for multidisciplinary care throughout the entire patient journey, ending with ideal approaches to recovery 6 months posttransplantation. Although the index case will focus on a theoretical patient with pulmonary fibrosis, the general management principles will be applicable across the entire spectrum of patients with ESLD presenting for lung transplantation.

Perioperative Outcomes During Double-Lung Transplantation and Retransplantation in Cystic Fibrosis Patients: A Monocentric Cohort Study.

OBJECTIVE: Life expectancy for lung-transplant patients, especially those with cystic fibrosis (CF), is leading increasingly to more retransplantations. DESIGN: Retrospective monocentric cohort study. SETTING: Foch University Hospital, Suresnes, France. PARTICIPANTS: CF patients having had a primary double-lung transplantation (pLgTx) or a retransplantation (reLgTx) from 2012 to 2021. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors compared the main intraoperative and early postoperative features between pLgTx (n = 258) and reLgTx (n = 24). Demographic characteristics were similar. No patients with retransplantations had a preoperative bridge with extracorporeal membrane oxygenation (ECMO); however, 23 patients had it in the pLgTx group (p = 0.24). Patients with retransplants had longer second graft ischemic time (p = 0.02), larger intraoperative bleeding volume (p = 0.001) and blood transfusion (p = 0.009 for packed red blood cells), increased blood lactate concentrations (p = 0.002), and higher norepinephrine dose at end-surgery (p = 0.001). Extracorporeal membrane oxygenation was used during surgery in 94 patients in the pLgTx group and 12 patients in the reLgTx group (p = 0.39). Extracorporeal membrane oxygenation could not be weaned after surgery in 55 patients in the pLgTx group and 4 in the reLgTx group (p = 0.54). Despite worse preoperative renal function in the reLgTx group (p < 0.001), there was no difference concerning renal replacement therapy in the intensive care unit between groups (p = 0.08). There were no differences between groups concerning the main complications, including primary graft dysfunction. Although the difference was not statistically different (p = 0.17), mortality was 3 times higher in the reLgTx group. CONCLUSIONS: Intraoperative period of retransplantation was more convoluted but had a similar ECMO profile to primary transplantation. In addition, the early postoperative period was similar.

Chronic pain after posterolateral and axillary approaches to lung surgery: a monocentric observational study.

PURPOSE: Post-thoracotomy pain syndrome (PTPS) and chronic postsurgical neuropathic pain (CPNP) were evaluated 4 months after thoracic surgery whether the approach was a posterolateral (PL) incision or the less invasive axillary (AX) one. METHODS: Patients, 79 in each group, undergoing a thoracotomy between July 2014 and November 2015 were analyzed 4 months after surgery in this prospective monocentric cohort study. RESULTS: More PL patients suffered PTPS (60.8% vs. 40.5%; p = 0.017) but CPNP was equally present (45.8% and 46.9% in the PL and AX groups). Patients with PTPS have more limited daily activities (p < 0.001) but a similar psychological disability (i.e., catastrophism). Patients with CPNP have an even greater limitation of daily activities (p = 0.007) and more catastrophism (p = 0.0002). Intensity of pain during mobilization of the homolateral shoulder at postoperative day 6 (OR = 1.40, CI 95% [1.13-1.75], p = 0.002); age (OR = 0.97 [0.94-1.00], p = 0.022), and presence of pain before surgery (OR = 2.22 [1.00-4.92], p = 0.049) are related to the occurrence of PTPS; while, height of hypoesthesia area on the breast line measured 6 days after surgery is the only factor related to that of CPNP (OR = 1.14 [1.01-1.30], p = 0.036). CONCLUSION: Minimally invasive surgery was associated with less frequent PTPS, but with equal risk of CPNP. Pain before surgery and its postoperative intensity are associated with PTPS. This must lead to a more aggressive care of pain patients before surgery and of a better management of postoperative pain. CPNP can be forecasted according to the early postoperative height of hypoesthesia area on the breast line.

Prevalence, Characteristics and Preoperative Predictors of Chronic Pain After Double-Lung Transplantation: A Prospective Cohort Study.

OBJECTIVE: Data on chronic pain after lung transplantation are heterogeneous. This study prospectively explored the prevalence, characteristics, consequences, and preoperative predictors of pain in lung transplant recipients. DESIGN: A prospective cohort study. SETTING: The Foch University Hospital, Suresnes, France. PARTICIPANTS: Patients registered on the waiting list for double-lung transplantation in the authors' institution from August 2008 to October 2013 and transplanted. INTERVENTIONS: Database prospectively completed in real time during consultations with a pain-certified anesthesiologist before lung transplantation and six months after surgery. MEASUREMENTS AND MAIN RESULTS: The assessments explored pain in three components: physical (intensity, location, neuropathic and sensory qualifications, treatments), mental (anxiety and depression), and quality of life. Seventy-two patients underwent all assessments. The prevalence of six-month postoperative pain was 68.0%. Among patients with pain, 83.3% reported mild average pain and 26.5% had neuropathic pain. All patients who responded to the questionnaire took analgesics frequently, but only 9.1% took opioids. Patients with pain reported higher levels of anxiety (p = 0.02) and depression (p = 0.01). Additionally, they presented with increased difficulty in ambulation (p = 0.03), work (p = 0.02), and sleep (p = 0.02). The maximum level of preoperative pain was an independent risk factor of six-month postoperative pain (p = 0.03). CONCLUSIONS: The authors report a high prevalence of chronic pain with concomitant psychosocial repercussions despite a reported mild intensity. Perioperative measures, such as personalized and detailed management plans, could improve patient satisfaction.

Feasibility and Usefulness of Self-Hypnosis in Patients Undergoing Double-Lung Transplantation During the Pre- and Postoperative Periods: A Randomized Study.

OBJECTIVE: Hypnosis can reduce pain and anxiety in surgical patients. This study aimed to demonstrate that implementing self-hypnosis in the setting of lung transplantation could improve patients' pain and quality of life. DESIGN: A randomized, single-center study. SETTING: Foch University Hospital, Suresnes, France. PARTICIPANTS: The participants were patients aged 15 years or older who needed a double-lung transplant. Patients were excluded if they participated in only 1 learning self-hypnosis session before transplantation. INTERVENTIONS: Patients were included at the time of their final evaluation before inscription on the waiting list. They were taught self-hypnosis at this time and were asked to perform it by themselves before and after transplantation, as frequently as possible. MEASUREMENTS AND MAIN RESULTS: The main outcome of the study was self-reported pain 1 month after lung transplantation. Secondary outcomes were self-reported pain, anxiety, coping, catastrophism, and self-reported quality of life evaluated at their registration, 7 days and 1 and 4 months after the transplantation. Seventy-eight patients were included, but only 28 patients in the control group and 33 in the self-hypnosis group were evaluated at the fourth postoperative month. Practice of self-hypnosis was high before transplantation (76.6%), lower after, from 32.3% in the intensive care unit to 51.6% during the last 3 months of the study. Group-time interactions were not statistically significant whatever the concerned outcome, especially pain score at 1 month (p = 0.16). CONCLUSION: Implementation of self-hypnosis is possible, but the study failed to demonstrate an improvement in patients' experience, perhaps due to the variable compliance with the technique.

Blood Lactate During Double-Lung Transplantation: A Predictor of Grade-3 Primary Graft Dysfunction.

OBJECTIVE: Many prognostic factors of grade-3 primary graft dysfunction at postoperative day 3 (PGD3-T72) have been reported, but intraoperative blood lactate level has not been studied. The present retrospective study was done to test the hypothesis that intraoperative blood lactate level (BLL) could be a predictor of PGD3-T72 after double-lung transplantation. DESIGN: Retrospective monocentric cohort study. SETTING: Foch University Hospital, Suresnes, France. PARTICIPANTS: Patients having received a double-lung transplantation between 2012 and 2019. Patients transplanted twice during the study period, having undergone a multiorgan transplantation, or cardiopulmonary bypass, and those under preoperative extracorporeal membrane oxygenation, were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Analysis was performed on a cohort of 449 patients. Seventy-two (16%) patients had a PGD3-T72. Blood lactate level increased throughout surgery to reach a median value of 2.2 (1.6-3.2) mmol/L in the No-PGD3-T72 group and 3.4 (2.3-5.0) mmol/L in the PGD3-T72 group after second lung implantation. The best predictive model for PGD3-T72 was obtained adding a lactate threshold of 2.6 mmol/L at the end of surgery to the clinical model, and the area under the curve was 0.867, with a sensitivity = 76.9% and specificity = 85.4%. Repeated-measures mixed model of BLL during surgery remained significant after adjustment for covariates (F ratio= 4.22, p < 0.001 for interaction). CONCLUSIONS: Blood lactate level increases during surgery and reaches a maximum after the second lung implantation. A value below the threshold of 2.6 mmol/L at the end of surgery has a high negative predictive value for the occurrence of a grade-3 primary graft dysfunction at postoperative day 3.

A virtual crossmatch-based strategy for perioperative desensitisation in lung transplant recipients with pre-formed donor-specific antibodies: 3-year outcome.

BACKGROUND: Pre-formed donor-specific antibodies (DSAs) are associated with worse outcome after lung transplantation (LTx) and might limit access to LTx. A virtual crossmatch-based strategy for perioperative desensitisation protocol has been used for immunised LTx candidates since 2012 at Foch Hospital (Suresnes, France). We compared the outcome of desensitised LTx candidates with high DSA mean fluorescence intensity and those with low or no pre-formed DSAs, not desensitised. METHODS: For all consecutive LTx recipients (January 2012 to March 2018), freedom from chronic lung allograft dysfunction (CLAD) and graft survival were assessed using Kaplan-Meier analysis and Cox multivariate analysis. RESULTS: We compared outcomes for desensitised patients with high pre-formed DSAs (n=39) and those with no (n=216) or low pre-formed DSAs (n=66). The desensitisation protocol decreased the level of immunodominant DSA (class I/II) at 1, 3 and 6 months post-LTx (p<0.001, p<0.01 and p<0.001, respectively). Freedom from CLAD and graft survival at 3 years was similar in the desensitised group as a whole and other groups. Nevertheless, incidence of CLAD was higher with persistent high-level DSAs than cleared high-level (p=0.044) or no DSAs (p=0.014). Conversely, graft survival was better with cleared high DSAs than persistent high-level, low-level and no pre-formed DSAs (p=0.019, p=0.025 and p=0.044, respectively). On multivariate analysis, graft survival was associated with cleared high DSAs (hazard ratio 0.12, 95% CI 0.02-0.85 versus no DSAs; p=0.035) and CLAD with persistent DSAs (3.04, 1.02-9.17 versus no pre-formed DSAs; p=0.048). CONCLUSION: The desensitisation protocol in LTx recipients with high pre-formed DSAs was associated with satisfactory outcome, with cleared high pre-formed DSAs after desensitisation identified as an independent predictor of graft survival.

Intraoperative Implications of the Recipients' Disease for Double-Lung Transplantation.

OBJECTIVES: To compare intraoperative patterns among patients based on their primary pulmonary disease (cystic fibrosis [CF], chronic obstructive pulmonary disease [COPD]/emphysema [CE], and pulmonary fibrosis [PF]) during double- lung transplantation. The following 3 major outcomes were reported: blood transfusion, extracorporeal membrane oxygenation (ECMO) management, and the possibility of immediate extubation at the end of surgery. DESIGN: Retrospective analysis of a prospectively maintained database, including donor and recipient characteristics and intraoperative variables. SETTING: Foch Hospital, Suresnes, France (academic center performing 60-80 lung transplantations per year). PARTICIPANTS: Patients who underwent double- lung transplantation from 2012-2019. Patients with retransplantation, multiorgan transplantation, or surgery performed with cardiopulmonary bypass were excluded. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Two hundred forty-six patients had CF, 117 had CE, and 66 had PF. No patient had primary pulmonary arterial hypertension. Blood transfusion was higher in the CF group than in the other 2 groups (red blood cells [p < 0.001], fresh frozen plasma [p = 0.004]). The CF and CE groups were characterized by a lower intraoperative requirement of ECMO (p = 0.002), and the PF group more frequently required postoperative ECMO (p < 0.001). CF and CE patients were more frequently extubated in the operating room than were PF patients (37.4%, 50.4%, and 13.6%, respectively; p < 0.001). CONCLUSIONS: Intraoperative outcomes differed depending on the initial pathology. Such differences should be taken into account in specific clinical studies and in intraoperative management protocols.

Prognostic value of the PaO2 /FiO2 ratio determined at the end-surgery stage of a double-lung transplantation.

INTRODUCTION: We evaluated the prognostic role of the arterial oxygen partial pressure/fractional inspired oxygen ratio (PaO2 /FiO2 ratio) measured at the end of double-lung transplantation (DLT). METHODS: This was a monocentric cohort study of all consecutive DLT patients between January 1, 2012, and January 1, 2016, except patients with preoperative extracorporeal membrane oxygenation (ECMO), intraoperative cardiopulmonary bypass, postoperative ECMO, large patent foramen ovale, redo transplantation during the study period, and multiorgan transplantation. RESULTS: A total of 164 patients were included in the study; 45 had a PaO2 /FiO2 ratio <200, 39 a ratio in the range 200-300, and 80 a ratio >300. The risk of being in the lower ratio group is positively related to body mass index, preoperative pulmonary hypertension, and fibrosis. It is negatively related to emergency surgery, age, and intraoperative institution of ECMO. There was a trend for more grade 3 pulmonary graft dysfunction at day 3 in the worst PaO2 /FiO2 ratio group. Mortality at 1000 days was similar for all patients and even after exclusion of patients who had required intraoperative ECMO. CONCLUSION: PaO2 /FiO2 ratio measured at the end of DLT does not forecast 1000-day mortality.

Inhaled nitric oxide dependency at the end of double-lung transplantation: a boosted propensity score cohort analysis.

Inhaled nitric oxide (iNO) is usually used during lung transplantation despite controversial postoperative benefits. Our group chose to administer iNO systematically during the procedure and stop at the end of surgery. This study aims to describe the features of patients who cannot be weaned from iNO, the reasons for this and its impact on postoperative outcomes. This is a monocentric cohort study comprised all consecutive patients who underwent double-lung transplantation (DLT) between 1 January 2012 and 1 January 2016. The impact of iNO dependency on postoperative outcomes was estimated using a boosted inverse probability of treatment weighting estimator. A total of 9.8% of the 173 patients included in the study could not be weaned from iNO at end-surgery stage. Body mass index (OR = 2.03, 95% CI = 1.14-3.29, P = 0.02) and intraoperative extracorporeal membrane oxygenation (OR = 1.80, 95% CI = 1.02-2.72, P = 0.04) were risk factors for iNO dependency In the weighted population, iNO dependency was associated with an increased prevalence of grade 3 primary graft dysfunction (adjusted RR = 4.20, 95% CI = 1.75-10.09, P < 0.001) and decreased postoperative survival during the first 1500 days of follow-up (adjusted HR = 5.0, 95% CI = 1.86-13.48, P < 0.001). Inhaled nitric oxide dependency is an early marker of a poor prognosis following DLT.

Early oral feeding after emergency abdominal operations: another paradigm to be broken?

PURPOSE OF REVIEW: The scope of this article is to provide an updated review examining the role of early feeding in the postoperative period. RECENT FINDINGS: Guidelines for postoperative care after abdominal surgery have historically outlined the dogma of 'nil by mouth' until bowel movement returns, but they are currently questioned. This change in mindset, especially after colorectal surgery, was initiated with fast-track or enhanced recovery after surgery programs, which particularly led to an opioid-sparing strategy. Many randomized trials and meta-analyses suggested an absence of benefit in keeping patients 'nil by mouth'. Conversely, in elective abdominal surgery, improvement in comfort without increased morbidity is now demonstrated with a liberal strategy, and a recent meta-analysis even demonstrated a decrease in mortality. Early caloric hydration and chewing gum are the most acceptable actions with a high level of proof. After emergency surgery, few data are available but a similar strategy should probably be chosen with no obvious benefit from maintenance of fasting. SUMMARY: Early oral intake is possible after elective abdominal surgery and should be moderate and progressive to be well tolerated. Any sign of nausea may mean intestinal or gastric disturbance and is a caution not to pursue this policy. The strategy in emergency abdominal surgery still requires adequately powered, randomized controlled trials.

Interest in the new thromboelastometry device, Clot Pro®, for predicting thrombocytopenia and hypofibrinogenemia during lung transplantation.

INTRODUCTION: Lung transplantation is associated with high proportion of transfusion. Monitoring of coagulopathy using viscoelastic tests could aid in the perioperative management of bleeding. The aim of the study was to assess the predictive cut-off values for thrombocytopenia and hypofibrinogenemia using the new thromboelastography analyzer, ClotPro. METHODS: We retrospectively enrolled 65 patients who underwent lung transplantation and were sampled for both viscoelastic assays and conventional coagulation assays simultaneously during the procedure. We characterized the correlation between the EX-test (extrinsic pathway) and platelet count as well as between the FIB-test (extrinsic pathway after platelet inhibition) and fibrinogen concentration. Then, we used ROC curve analysis to determine the optimal EX-test and FIB-test values for predicting thrombocytopenia and hypofibrinogenemia. RESULTS: All the amplitude values of the EX-test (A5, A10, A20, MCF) showed correlation with platelets count (Spearman's rank correlation coefficient ranging from 0.75 to 0.77, all p < 0.0001). We also observed a strong correlation between the amplitude values of the FIB-test (A5, A10, A20 and MCF) and the fibrinogen concentration (Spearman's rank correlation coefficient ranging from 0.68 to 0.71, all p < 0.0001). The AUCs of the EX-test values for thrombocytopenia <100 G/L and <80 G/L ranged from 0.80 to 0.93. Similarly, the AUCs of the FIB-test values for hypofibrinogenemia <1.5 g/L and <2 g/L ranged from 0.74 to 0.83. These results indicate that only the five-minute parameter of thromboelastometry is sufficient for detecting thrombocytopenia and hypofibrinogenemia in patients undergoing lung transplantation. The proposed cut off values for the EX-test to predict thrombocytopenia <80 G/L showed high sensitivity (>86 %), high specificity (>89 %) and high negative predictive value (>95 %). FIB-test cut off values predictive of fibrinogen below 1.5 g/L showed sensitivity (>78 %), specificity (>55 %) and negative predictive value (>88 %). CONCLUSIONS: Our study provided preliminary results that are useful for developing a ClotPro-based algorithm to guide transfusion in lung transplantation. Future interventional studies will be necessary to validate these cut-off values of ClotPro for guiding transfusion.

Protocol for venoarterial ExtraCorporeal Membrane Oxygenation to reduce morbidity and mortality following bilateral lung TransPlantation: the ECMOToP randomised controlled trial.

INTRODUCTION: Lung transplantation (LTx) aims at improving survival and quality of life for patients with end-stage lung diseases. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is used as intraoperative support for LTx, despite no precise guidelines for its initiation. We aim to evaluate two strategies of VA-ECMO initiation in the perioperative period in patients with obstructive or restrictive lung disease requiring bilateral LTx. In the control 'on-demand' arm, high haemodynamic and respiratory needs will dictate VA-ECMO initiation; in the experimental 'systematic' arm, VA-ECMO will be pre-emptively initiated. We hypothesise a 'systematic' strategy will increase the number of ventilatory-free days at day 28. METHODS AND ANALYSIS: We designed a multicentre randomised controlled trial in parallel groups. Adult patients with obstructive or restrictive lung disease requiring bilateral LTx, without a formal indication for pre-emptive VA-ECMO before LTx, will be included. Patients with preoperative pulmonary hypertension with haemodynamic collapse, ECMO as a bridge to transplantation, severe hypoxaemia or hypercarbia will be secondarily excluded. In the systematic group, VA-ECMO will be systematically implanted before the first pulmonary artery cross-clamp. In the on-demand group, VA-ECMO will be implanted intraoperatively if haemodynamic or respiratory indices meet preplanned criteria. Non-inclusion, secondary exclusion and VA-ECMO initiation criteria were validated by a Delphi process among investigators. Postoperative weaning of ECMO and mechanical ventilation will be managed according to best practice guidelines. The number of ventilator-free days at 28 days (primary endpoint) will be compared between the two groups in the intention-to-treat population. Secondary endpoints encompass organ failure occurrence, day 28, day 90 and year 1 vital status, and adverse events. ETHICS AND DISSEMINATION: The sponsor is the Assistance Publique-Hôpitaux de Paris. The ECMOToP protocol version 2.1 was approved by Comité de Protection des Personnes Ile de France VIII. Results will be published in international peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT05664204.

ISHLT consensus statement on the perioperative use of ECLS in lung transplantation: Part II: Intraoperative considerations.

The use of extracorporeal life support (ECLS) throughout the perioperative phase of lung transplantation requires nuanced planning and execution by an integrated team of multidisciplinary experts. To date, no multidisciplinary consensus document has examined the perioperative considerations of how to best manage these patients. To address this challenge, this perioperative utilization of ECLS in lung transplantation consensus statement was approved for development by the International Society for Heart and Lung Transplantation Standards and Guidelines Committee. International experts across multiple disciplines, including cardiothoracic surgery, anesthesiology, critical care, pediatric pulmonology, adult pulmonology, pharmacy, psychology, physical therapy, nursing, and perfusion, were selected based on expertise and divided into subgroups examining the preoperative, intraoperative, and postoperative periods. Following a comprehensive literature review, each subgroup developed recommendations to examine via a structured Delphi methodology. Following 2 rounds of Delphi consensus, a total of 39 recommendations regarding intraoperative considerations for ECLS in lung transplantation met consensus criteria. These recommendations focus on the planning, implementation, management, and monitoring of ECLS throughout the entire intraoperative period.

Comprehensive assessment of postoperative mobility during the first days after mini-invasive lung surgery: A prospective observational study.

STUDY OBJECTIVE: Postoperative physical therapy and early mobilization are major elements for enhanced recovery after surgery. In contrast with supervised physical therapy sessions that can be monitored, self-mobilization is not easily quantifiable and has so far been estimated mainly through patient auto-reports. This study aimed to perform a comprehensive and objective evaluation of postoperative mobility. DESIGN: Prospective observational study. SETTING: Postoperative setting. PATIENTS: Patients undergoing mini-invasive lung surgery. INTERVENTIONS: Measurement of postoperative mobility during the first five postoperative days using an accelerometer (ActiGraph GT3X). MEASUREMENTS: The primary outcome was the number of daily steps. Secondary outcomes included physical activity duration and intensity, sedentary time, number of breaks in sedentary time, sedentary patterns, daily evaluation by physiotherapists, postoperative complications, and acceptability of wearing the accelerometer. MAIN RESULTS: Sixty patients were included in the study, of whom 56 provided at least one day of valid accelerometry data. There was no significant change during the first four PODs concerning the number of daily steps nor the mean cadence. One-minute cadence peak, total activity counts, and duration of light-intensity physical activity increased over time (p = 0.032, p = 0.001 and p = 0.001, respectively). Sedentary patterns changed favorably over time, with a decrease in prolonged sedentary bouts (≥ 60 consecutive min) (p < 0.001), and an increase in shorter bouts (< 10 min) (p = 0.001). Similar results were observed when analysis was adjusted for the day of the week when the surgery took place. The median acceptability of wearing the accelerometer was excellent (median 10 [9-10] on a 10-point Likert scale). Three patients had major complications. CONCLUSIONS: Our findings suggest that daily steps may not be the only relevant indicator of early mobility following thoracic surgery and that accelerometry is suitable to follow patients' early postoperative activity.