Diffusion de la réhabilitation améliorée après chirurgie en France. Étude nationale à grande échelle, à partir des données du PMSI.

INTRODUCTION: The aim of this study was to analyze the rate of enhanced recovery programs (ERP) implementation in a range of surgical specialties in both the public and private sectors. METHODS: This was a retrospective longitudinal study based on hospital stays between March to December 2019. We studied thirteen of the activity segments most frequently included in ERP protocol. The procedures selected included digestive, gynecological, orthopedic, thoracic, and urological procedures. The assessment criteria was the rate of ERP. The results were analyzed first overall and then matching ERP stays to non-ERP stays according to type of institution, patient age and sex, month of discharge, and Charlson comorbidity score. RESULTS: We took 420,031 stays into account, of which 78,119 were coded as ERP. There were 62,403 non-ERP stays. Depending on the type of surgery, the implementation rate ranged from 5 percent to 30 percent. The overall rate of ERP implementation was higher in the private sector (21.2 percent) than in the public sector (14.4 percent). The results are reversed for some surgeries, notably for some cancers. Patients had a higher Charlson score in the public sector. CONCLUSIONS: This large-scale national study provides a picture of the degree of diffusion of ERPs in France. Although there are differences between sectors, this diffusion is still insufficient overall. Given the demonstrated benefits of ERPs, more educational efforts are needed to improve their implementation in France.

Comparison of continuous with single-injection regional analgesia on patient experience after ambulatory orthopaedic surgery: a randomised multicentre trial.

BACKGROUND: The optimal approach to improving patient experience and analgesia after ambulatory orthopaedic surgery remains unclear. METHODS: This multicentre, randomised clinical trial compared single-injection nerve block analgesia with home delivery of continuous nerve block analgesia by remote-controlled electronic pump. The primary outcome was patient-reported satisfaction (Evaluation du Vecu de l'Anesthesie Generale [EVAN-G]; 0-100) assessed on postoperative Day 2. Secondary outcomes focused on pain, opioid consumption, quality of rehabilitation, activity tracking using a wearable electronic device, and 90-day quality of life. RESULTS: We randomly assigned 294 patients to continuous pump delivery or single injection. For subjects with normal level of pain catastrophising (Pain Catastrophizing Scale <30; n=211), median global EVAN-G was higher with the electronic pump compared with the single injection (78 [69-86] vs 72 [63-84]; P=0.03), as were pain satisfaction scores (P=0.01). For the maximum pain levels, the numerical rating scale score was 2.0 (1.0-5.0) in the electronic-pump group vs 5.0 (3.0-7.0) in the single-injection group on the first 2 days after surgery (P<0.0001). Total opioid consumption in morphine equivalent was higher with single injection (mean [standard deviation]): 70.5 [73.8] vs 31.9 [54.2] mg; P<0.01). The groups did not differ in early rehabilitation on Day 1 or quality of life on Day 45. Electronic activity tracking indicated higher activity in the electronic-pump group (P<0.01). CONCLUSIONS: Self-reported patient satisfaction at home was better with continuous nerve block analgesia via electronic pump vs single injection, without impairing early rehabilitation. Single-injection analgesia was associated with higher pain levels and opioid consumption and lower satisfaction. Patient catastrophising negatively affected the experience of pain. CLINICAL TRIAL REGISTRATION: NCT02720965.

Medico-economic impact of enhanced rehabilitation after surgery: an exhaustive, nation-wide claims study.

BACKGROUND: Study of the medico economic impact of enhanced rehabilitation after surgery (ERAS), by comparing the cost of patient care with or without ERAS, both from the point of view of the hospitals and the Social Security Health Insurance Program. METHODS: Retrospective longitudinal study on matched data from March 1, 2019 to December 31, 2019. The data are extracted from the French prospective payment system. We studied 12 of the most commonly performed in ERAS business segments. The primary outcome was the reduction of the average length of hospital stay and its implications on production costs and excess capacity. We also studied the impact on hospital incomes and Social Security Insurance Program expenses. The potential gain in hospital days was computed by comparing the length of stay of ERAS and non-ERAS cases. The cost reduction was estimated using the mean number of avoidable days of hospitalization, and the mean cost of the stays obtained from the national cost study. Finally, we studied an approximation of the additional expense for the Social Security Health Insurance Program on costs standardized by applying public sector rates. RESULTS: The average length of stay reduction attributed to ERAS is 1.45 (CI 95% 1.42 to 1.48) day per stay, translating to a cost reduction for the hospitals of € 1060 (CI 95% 995 to 1125) per patient and a total of €65 million (CI 95% 61 to 69). At the same time, the additional expenses for the Social Security Insurance Program can conservatively be approximated to € 1.6 million, breaking into a € 2.2 million increase partially compensated by cost savings of € 0.6 million over subsequent stays for complications. Overall, for each percent of additional ERAS activity over the scope of the study, the marginal cost reduction for the hospitals can be estimated to € 1.8 million (CI 95% 1.7 million to 2.0 million). CONCLUSIONS: Associated with previously known clinical benefits for the patients, these convincing results in terms of economic gain strongly support expanding the adoption of ERAS.

Use of ultrasound for lower extremity.

PURPOSE OF REVIEW: To explore the recent advances in the use of ultrasound for lower extremity blocks, including approaches to the lumbar and sacral plexus blocks. RECENT FINDINGS: Procedures of the lower extremity often require blocks of the lumbar and sacral plexuses. The use of ultrasound offers some advantages, including the possibility to directly visualize the distribution of local anesthetics. SUMMARY: Lower extremity blocks under ultrasound guidance often require advanced skills because of the depth of target nerves. This review summarizes the recent advances in the use of ultrasound guidance over traditional techniques.

Hypnosis versus diazepam for embryo transfer: a randomized controlled study.

Levitas et al. (2006) showed in a cohort study that hypnosis during embryo transfer (ET) increased pregnancy ratio by 76%. In order to evaluate hypnosis during ET in a general population, the authors performed a randomized prospective controlled study comparing diazepam (usual premedication) administered before ET plus muscle relaxation versus hypnosis plus placebo in 94 patients. Additionally, the authors studied anxiety pre and post ET. Anxiety scores were not different in the two groups before and after ET. No difference in pregnancy and birth ratio was found in the two groups. Hypnosis during ET is as effective as diazepam in terms of pregnancy ratio and anxiolytic effects, but with fewer side effects and should be routinely available.

Favorable effect of enhanced recovery programs on post-discharge mortality: a French nationwide study.

BACKGROUND: Enhanced recovery programs (ERPs) imply early discharge but few papers have assessed the effect of ERPs on post-discharge mortality (PDM). METHODS: A multicenter nationwide case control study based on administrative data was carried out between March and December 2019. Coding for every episode of care whether in the setting of ERP or not is mandatory for hospital funding (public or private). Twelve surgical specialties or procedures were included. The episodes of care coded with ERP were matched with those without ERP code for several factors such as the type of hospital (public or private), age, gender, month of discharge, and updated Charlson score. Ninety-day PDM was the main outcome. RESULTS: Of 420,031 patients in the database, 78,119 had an ERP code. Finally, 132,600 patients with 66,300 matched pairs were considered for the study. Overall, PDM was significantly reduced after ERPs: 0.075% vs 0.138% (p = 0.00042). Significant one-half and two-thirds reduction in PDM was observed respectively after hip arthroplasty (odds ratio 0.48 [95% CI 0.21-0.99]) and colectomy (odds ratio 0.36 [95% CI 0.16-0.74]). CONCLUSION: The findings, based on a large database and a rigorous matching, strongly suggest that ERPs reduce PDM particularly after colectomy and hip arthroplasty. This is likely due to better post-operative care in ERPs.

Effects of a training program in medical hypnosis on burnout in anesthesiologists and other healthcare providers: A survey study.

OBJECTIVE: To determine whether the participation to a medical hypnosis training program reduces the levels of burnout in healthcare providers. DESIGN: Survey study. SETTINGS: Study conducted from 2014 to 2018 using the MBI-HSS questionnaire assessing three dimensions of burnout: emotional exhaustion (EE), depersonalization (DP) and personal accomplishment (PA). PARTICIPANTS: Healthcare providers in particular anesthesiologists participating to a one-year medical hypnosis training program. INTERVENTION: All participants were asked to fill the MBI-HSS on the first day before the training program had begun, then on the last day of the program once the entire training was completed. PRIMARY AND SECONDARY OUTCOME MEASURES: The EE, DP and PA scores and their grade (high, average and low) were compared before and after training and between physicians and caregivers. RESULTS: In total, 1850 persons participated to the training sessions, with 1366 participants enrolled before the first session (74%) and 1407 (76%) after the fourth. On the 1366 persons enrolled before training, 1139 (83%) completed the survey and on the 1407 enrolled after training, 1194 (85%) completed the survey. The scores were significantly smaller after training for EE and DP and significantly greater for PA. Before training, EE was significantly greater in physicians than in caregivers as well as DP, with no difference for PA. After training, DP was significantly greater in physicians than in caregivers and PA was smaller, with no difference for EE. Before training, there was high rates of burnout in both healthcare providers but there was a significant trend to smaller rates of burnout after training. CONCLUSIONS: This study shows that healthcare providers who participated to a medical hypnosis training program presented improvements in the three dimensions of burnout. Further study is required to investigate and recommend this type of continuous medical education to improve professional satisfaction and wellbeing in healthcare providers.

Impact of Chloroprocaine on the Eligibility for Hospital Discharge in Patients Requiring Ambulatory Surgery Under Spinal Anesthesia: An Observational Multicenter Prospective Study.

INTRODUCTION: This observational study was designed to assess the use of spinal anesthesia with chloroprocaine in the context of ambulatory surgery. METHODS: A prospective, multicenter, observational study was carried out among 33 private or public centers between May 2014 and January 2015 and adult patients, scheduled for a short ambulatory surgery under spinal anesthesia with chloroprocaine. The primary outcomes were anesthetic effectiveness, defined as performance of the whole surgical procedure without any additional anesthetic agent, and the time to achieve eligibility for hospital discharge. Secondary outcomes were the effect of chloroprocaine on motor and sensory blocks, patients' satisfaction, and the use of analgesics in the first 24 h after surgery. RESULTS: Among the 615 enrolled patients, 56% were male, the mean age was 47.2 ± 15.2 years, and most patients had an ASA (American Society of Anesthesiologists) status of 1 (63.7%). Main surgical procedures performed were orthopedic (62.6%) and gynecologic (16.1%), and the mean duration of surgery was 26.7 ± 16.7 min. The overall anesthetic success rate was 93.8% (95% CI [91.5%; 95.6%]) for the 580 patients with available data for primary criteria. The failure rate was lower than 7% for all surgical procedures, except for gynecologic surgery (14.8%; 95% CI [8.1%; 23.9%]). The average times of eligibility for hospital discharge and effective discharge were 252.7 ± 82.7 min and 313.8 ± 109.9 min, respectively. The time of eligibility for hospital discharge is defined as the recovery of the patient's normal clinical parameters and the time of effective discharge is defined as the time for the patient to leave the hospital after surgery. Eligibility for patient's discharge was achieved more rapidly in private than public hospitals (236.3 ± 77.2 min vs. 280.9 ± 80.7 min, respectively, p < 0.001). CONCLUSIONS: This study showed positive results on the effectiveness of chloroprocaine as a short-duration anesthetic and could be used to reduce the time to achieve eligibility for hospital discharge. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT02152293. Registered on May 6, 2014. Date of enrollment of the first participant in the trial May 7, 2014.

Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study.

INTRODUCTION: Available short-acting intrathecal anesthetic agents (chloroprocaine and prilocaine) offer an alternative to general anesthesia for short-duration surgical procedures, especially ambulatory surgeries. Factors determining the choice of anesthesia for short-duration procedures have not been previously identified. METHODS: This observational, prospective, multicenter, cohort study was conducted between July 2015 and July 2016, in 33 private or public hospitals performing ambulatory surgery. The primary objective was to determine the factors influencing the choice of anesthetic technique (spinal or general anesthesia). Secondary outcomes included efficacy of the anesthesia, time to hospital discharge, and patient satisfaction. RESULTS: Among 592 patients enrolled, 309 received spinal anesthesia and 283 underwent general anesthesia. In both study arms, the most frequently performed surgical procedures were orthopedic and urologic (43.3% and 30.7%, respectively); 66.1% of patients were free to choose their type of anesthesia, 21.8% chose one of the techniques because they were afraid of the other, 16.8% based their choice on the expected ease of recovery, 19.2% considered their degree of anxiety/stress, and 16.9% chose the technique on the basis of its efficacy. The median times to micturition and to unassisted ambulation were significantly shorter in the general anesthesia arm compared with the spinal anesthesia arm (225.5 [98; 560] min vs. 259.0 [109; 789] min; p = 0.0011 and 215.0 [30; 545] min vs. 240.0 [40; 1420]; p = 0.0115, respectively). The median time to hospital discharge was equivalent in both study arms. In the spinal anesthesia arm, patients who received chloroprocaine and prilocaine recovered faster than patients who received bupivacaine. The time to ambulation and the time to hospital discharge were shorter (p < 0.001). The overall success rate of spinal anesthesia was 91.6%, and no significant difference was observed between chloroprocaine, prilocaine, and bupivacaine. The patients' global satisfaction with anesthesia and surgery was over 90% in both study arms. CONCLUSIONS: Patient's choice, patient fear of the alternative technique, patient stress/anxiety, the expected ease of recovery, and the efficacy of the technique were identified as the main factors influencing patient choice of short-acting local anesthesia or general anesthesia. Spinal anesthesia with short-acting local anesthetics was preferred to general anesthesia in ambulatory surgeries and was associated with a high degree of patient satisfaction. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02529501. Registered on June 23, 2015. Date of enrollment of the first participant July 21, 2015.

Analgesia after arthroscopic rotator cuff repair: subacromial versus interscalene continuous infusion of ropivacaine.

OBJECTIVES: A continuous infusion of local anesthetic in the subacromial space has been shown to provide superior pain relief compared with placebo. This technique has been considered as an alternative to a continuous interscalene infusion. The aim of our study is to compare these 2 techniques for pain relief after arthroscopic rotator cuff repair. METHODS: In a prospective randomized trial, 30 consecutive patients undergoing rotator cuff repair were included. An interscalene brachial plexus block was performed in all patients with mepivacaine 1.5% 30 mL. Then, 15 patients had an indwelling interscalene catheter inserted immediately after the block via a needle. Fifteen other patients had a subacromial catheter placed at the end of surgery by the surgeon. In both groups, a 2 mg/mL ropivacaine continuous infusion (5 mL/h) with PCA bolus (5 mL/30 min) was maintained for 48 hours. Pain was assessed in PACU and at 24 and 48 hours after surgery, at rest, and during passive motion. Total amount of oral morphine self-administered as rescue analgesia and cumulative 24-hour and 48-hour local anesthetic consumption were noted. Patient satisfaction and side effects were also noted. RESULTS: Pain during motion in PACU (0 [0 to 60] v 40 [0 to 100] mm) and at 24 hours (10 [0 to 60] v 45 [20 to 100] mm), oral morphine (0 [0 to 6] v 3.5 [0 to 10] morphine capsules), and total amount of local anesthetic at 24 hours (122.5 [120 to 170] v 143 [129 to 250] mg) were lower in the continuous interscalene group. Local anesthetic side effects were less frequent in the continuous subacromial group. Satisfaction was comparable between groups. CONCLUSION: After arthroscopic rotator cuff repair, continuous interscalene block provides better analgesia compared with continuous subacromial infusion but with an increased incidence of minor side effects.

Pleural effusion and chest pain after continuous interscalene brachial plexus block.

OBJECTIVE: We describe a unique case of a patient who experienced atelectasis of the lower lobe of the left lung and pleural effusion manifested by chest pain after continuous interscalene brachial plexus block for postoperative analgesia. CASE REPORT: A 45-year-old man with no respiratory disease was scheduled for left shoulder arthroscopy for rotator cuff repair under interscalene brachial plexus block and sedation. A continuous interscalene brachial plexus block provided postoperative analgesia. On the first postoperative day, the patient reported left-sided chest pain. The chest x-ray showed elevation of the left hemidiaphragm associated with a left lower lobe atelectasis and a minor pleural effusion. After catheter removal, clinical and radiologic signs resolved within few days without sequela. CONCLUSION: If chest pain presents after interscalene brachial plexus block, early postoperative chest x-ray is recommended to rule out pneumothorax, atelectasis, and/or pleural effusion secondary to ipsilateral phrenic block.

Intrathecal morphine provides better postoperative analgesia than psoas compartment block after primary hip arthroplasty.

PURPOSE: Intrathecal morphine and psoas compartment block represent two accepted techniques to provide postoperative analgesia after hip arthroplasty. We designed a prospective, randomized, single-blinded study to compare these two techniques. METHODS: Patients scheduled for primary hip arthroplasty under general anesthesia were randomized to receive either an intrathecal administration of 0.1 mg morphine (Group I, n = 27) or a psoas compartment block with ropivacaine 0.475% 25 mL (Group II, n = 26). Pain scores, morphine consumption, associated side-effects were assessed for 48 hr postoperatively. In addition, patient's acceptance and satisfaction of the postoperative analgesic technique were also recorded. RESULTS: During the first 24 hr, pain scores (3.3 +/- 9.6 mm vs 22.8 +/- 27.1 at H+6, 3.3 +/- 8.3 mm vs 25 +/- 26.7 mm at H+12, 7 +/- 14.9 mm vs 21.9 +/- 29 mm at H+18) and morphine consumption (0.56 +/- 2.12 mg vs 9.42 +/- 10.13 mg) were lower in Group I than in Group II. Urinary retention was the more frequent side-effect occurring in 37% of cases in Group I vs 11.5% in Group II (P < 0.05). No major complication occurred. Despite better analgesia provided by the use of intrathecal morphine, there was no difference in the satisfaction scores between groups. CONCLUSION: 0.1 mg intrathecal morphine administration provides better postoperative analgesia than single-shot psoas compartment block after primary hip arthroplasty.

Outpatient lower extremity infusions.

The considerable development of ambulatory surgery has led to an increase in the number of lower extremity procedures performed in an outpatient setting. More recently, the availability of disposable pumps has allowed us to extend the indications of continuous nerve blocks for ambulatory post-operative pain management. Indications for lumbar plexus continuous blocks include anterior cruciate ligament (ACL) reconstruction and patella repairs as well as frozen knee, whereas continuous sciatic blocks are indicated for major foot and ankle surgery. Different modes of local anaesthetic administration have been applied, including the use of repeated bolus, continuous administration and, more recently, patient-controlled perineural infusions. This latter technique seems to be the preferred mode because it offers the advantage of tailoring the amount of local anaesthetics, mostly 0.2% ropivacaine, to the individual need and also maximizes the duration of infusion for a given volume of local anaesthetic. Although the preliminary reports indicate that lower extremity continuous blocks provide effective post-operative ambulatory analgesia and are safe, especially as a part of a multimodal approach, appropriate training in these techniques represents one of the most important limiting factors of the placement of perineural catheters. Additional research is required to determine the optimal conditions in which these techniques are indicated.