Upper gastrointestinal bleeding on veno-arterial extracorporeal membrane oxygenation support.

INTRODUCTION: Patients on veno-arterial extracorporeal membrane oxygenation (V-A ECMO) support are at a high risk of hemorrhagic complications, including upper gastrointestinal bleeding (UGIB). The objective of this study was to evaluate the incidence and impact of this complication in V-A ECMO patients. MATERIALS AND METHODS: A retrospective single-center study (2013-2017) was conducted on V-A ECMO patients, excluding those who died within 24 h. All patients with suspected UGIB underwent esophagogastroduodenoscopy (EGD) and were analyzed and compared to the remainder of the cohort, from the initiation of ECMO until 5 days after explantation. RESULTS: A total of 150 V-A ECMO cases (65 after cardiac surgery and 85 due to medical etiology) were included. 90% of the patients received prophylactic proton pump inhibitor therapy and enteral nutrition. Thirty-one patients underwent EGD for suspected UGIB, with 16 confirmed cases of UGIB. The incidence was 10.7%, with a median occurrence at 10 [7-17] days. There were no significant differences in clinical or biological characteristics on the day of EGD. However, patients with UGIB had significant increases in packed red blood cells and fresh frozen plasma needs, mechanical ventilation duration and V-A ECMO duration, as well as in length of intensive care unit and hospital stays. There was no significant difference in mortality. The only independent risk factor of UGIB was a history of peptic ulcer (OR = 7.32; 95% CI [1.07-50.01], p = 0.042). CONCLUSION: UGIB occurred in at least 1 out of 10 cases of V-A ECMO patients, with significant consequences on healthcare resources. Enteral nutrition and proton pump inhibitor prophylaxis did not appear to protect V-A ECMO patients. Further studies should assess their real benefits in these patients with high risk of hemorrhage.

Preoperative ketamine administration for prevention of postoperative neurocognitive disorders after major orthopedic surgery in elderly patients: A multicenter randomized blinded placebo-controlled trial.

BACKGROUND: Preventive anesthetic impact on the high rates of postoperative neurocognitive disorders in elderly patients is debated. The Prevention of postOperative Cognitive dysfunction by Ketamine (POCK) study aimed to assess the effect of ketamine on this condition. METHODS: This is a multicenter, randomized, double-blind, interventional study. Patients ≥60 years undergoing major orthopedic surgery were randomly assigned in a 1:1 ratio to receive preoperative ketamine 0.5 mg/kg as an intravenous bolus (n = 152) or placebo (n = 149) in random blocks stratified according to the study site, preoperative cognitive status and age. The primary outcome was the proportion of objective delayed neurocognitive recovery (dNR) defined as a decline of one or more neuropsychological assessment standard deviations on postoperative day 7. Secondary outcomes included a three-month incidence of objective postoperative neurocognitive disorder (POND), as well as delirium, anxiety, and symptoms of depression seven days and three months after surgery. RESULTS: Among 301 patients included, 292 (97%) completed the trial. Objective dNR occurred in 50 (38.8%) patients in the ketamine group and 54 (40.9%) patients in the placebo group (OR [95% CI] 0.92 [0.56; 1.51], p = 0.73) on postoperative day 7. Incidence of objective POND three months after surgery did not differ significantly between the two groups nor did incidence of delirium, anxiety, apathy, and fatigue. Symptoms of depression were less frequent in the ketamine group three months after surgery (OR [95% CI] 0.34 [0.13-0.86]). CONCLUSIONS: A single preoperative bolus of intravenous ketamine does not prevent the occurrence of dNR or POND in elderly patients scheduled for major orthopedic surgery. (Clinicaltrials.gov NCT02892916).

Lung Ultrasound Score on Postoperative Day 1 Is Predictive of the Occurrence of Pulmonary Complications after Major Abdominal Surgery: A Multicenter Prospective Observational Study.

BACKGROUND: Postoperative pulmonary complications after major abdominal surgery are frequent and carry high morbidity and mortality. Early identification of patients at risk of pulmonary complications by lung ultrasound may allow the implementation of preemptive strategies. The authors hypothesized that lung ultrasound score would be associated with pulmonary postoperative complications. The main objective of the study was to evaluate the performance of lung ultrasound score on postoperative day 1 in predicting pulmonary complications after major abdominal surgery. Secondary objectives included the evaluation of other related measures for their potential prediction accuracy. METHODS: A total of 149 patients scheduled for major abdominal surgery were enrolled in a bicenter observational study. Lung ultrasound score was performed before the surgery and on days 1, 4, and 7 after surgery. Pulmonary complications occurring before postoperative day 10 were recorded. RESULTS: Lung ultrasound score on postoperative day 1 was higher in patients developing pulmonary complications before day 10 (median, 13; interquartile range, 8.25 to 18; vs. median, 10; interquartile range, 6.5 to 12; Mann-Whitney P = 0.002). The area under the curve for predicting postoperative pulmonary complications before day 10 was 0.65 (95% CI, 0.55 to 0.75; P = 0.003). Lung ultrasound score greater than 12 had a sensitivity of 0.54 (95% CI, 0.40 to 0.67), specificity of 0.77 (95% CI, 0.67 to 0.85), and negative predictive value of 0.74 (95% CI, 0.65 to 0.83). Lung ultrasound score greater than 17 had sensitivity of 0.33 (95% CI, 0.21 to 0.47), specificity of 0.95 (95% CI, 0.88 to 0.98), and positive predictive value of 0.78 (95% CI, 0.56 to 0.93). Anterolateral lung ultrasound score and composite scores using lung ultrasound score and other patient characteristics showed similar predictive accuracies. CONCLUSIONS: An elevated lung ultrasound score on postoperative day 1 is associated with the occurrence of pulmonary complications within the first 10 days after major abdominal surgery.

Pain management after thoracic surgery or chest trauma.

Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.

Risk factors and prognostic significance of infection of totally implantable vascular access port in solid tumor patients: A prospective cohort study.

OBJECTIVES: Totally implantable venous access ports (TIVAP) are devices mainly used to deliver antineoplastic chemotherapies, of which the insertion may be complicated by TIVAP-related infection (TIVAP-RI). This study aims to provide data on the risk factors for TIVAP-RI and its influence on patient prognosis. PATIENTS AND METHODS: Prospective observational study including adult patients with solid tumors, in whom a TIVAP was inserted to deliver antineoplastic chemotherapy between January 2018 and October 2019. Factors associated with TIVAP-RI and one-year mortality were determined using multiple logistic regressions. RESULTS: More than a thousand (1014) patients were included, among whom 48 (4.7%) presented with TIVAP-RI. Gram-positive cocci and Gram-negative bacilli represented 51% and 41% of the pathogens isolated, respectively. Young age (odds ratio [OR] 0.67; 95% Confidence Interval [0.53-0.83] per 10-year increase), WHO performance status ≥ 1 (OR 3.24 [1.52-7.79]), chemotherapy administration in the month before TIVAP placement (OR 2.26 [1.17-4.26]), and radiation therapy of the homolateral chest wall (OR 3.28 [1.51-6.67]) were independently associated with TIVAP-RI occurrence. During the year following TIVAP insertion, 287 (28%) patients died. TIVAP-RI was not associated with one-year mortality (OR 1.56 [0.75-3.19]). CONCLUSION: TIVAP insertion in adult patients with solid tumors is associated with a low infection rate, which did not influence one-year mortality. In addition to young age and impaired health status, TIVAP insertion in the month following initiation of the antineoplastic chemotherapy and TIVAP insertion in an irradiated area are two newly reported preventable TIVAP-RI risk factors.

Association of preoperative COVID-19 and postoperative respiratory morbidity during the Omicron epidemic wave: the DROMIS-22 multicentre prospective observational cohort study.

Background: Preoperative COVID-19 has been associated with excess postoperative morbi-mortality. Consequently, guidelines were developed that recommended the postponement of surgery for at least 7 weeks after the infection. We hypothesised that vaccination against the SARS-CoV-2 and the large predominance of the Omicron variant attenuated the effect of a preoperative COVID-19 on the occurrence of postoperative respiratory morbidity. Methods: We conducted a prospective cohort study in 41 French centres between 15 March and 30 May 2022 (ClinicalTrials NCT05336110), aimed at comparing the postoperative respiratory morbidity between patients with and without preoperative COVID-19 within 8 weeks prior to surgery. The primary outcome was a composite outcome combining the occurrence of pneumonia, acute respiratory failure, unexpected mechanical ventilation, and pulmonary embolism within the first 30 postoperative days. Secondary outcomes were 30-day mortality, hospital length-of-stay, readmissions, and non-respiratory infections. The sample size was determined to have 90% power to identify a doubling of the primary outcome rate. Adjusted analyses were performed using propensity score modelling and inverse probability weighting. Findings: Of the 4928 patients assessed for the primary outcome, of whom 92.4% were vaccinated against the SARS-CoV-2, 705 had preoperative COVID-19. The primary outcome was reported in 140 (2.8%) patients. An 8-week preoperative COVID-19 was not associated with increased postoperative respiratory morbidity (odds ratio 1.08 [95% CI 0.48-2.13]; p = 0.83). None of the secondary outcomes differed between the two groups. Sensitivity analyses concerning the timing between COVID-19 and surgery, and the clinical presentations of preoperative COVID-19 did not show any association with the primary outcome, except for COVID-19 patients with ongoing symptoms the day of surgery (OR 4.29 [1.02-15.8]; p = 0.04). Interpretation: In our Omicron-predominant, highly immunised population undergoing general surgery, a preoperative COVID-19 was not associated with increased postoperative respiratory morbidity. Funding: The study was fully funded by the French Society of Anaesthesiology and Intensive Care Medicine (SFAR).

Gastric Cross-Sectional Area to Predict Gastric Intolerance in Critically Ill Patients: The Sono-ICU Prospective Observational Bicenter Study.

To evaluate the correlation between gastric cross-sectional area (GCSA) and the occurrence of gastric intolerance in critically ill patients within 24 hours of the measurement. DESIGN: Two-center prospective observational study. SETTING: Two academic ICUs in France between June 2020 and August 2021. PATIENTS: All surgical intubated ICU patients greater than or equal to 18 years old receiving enteral feeding for greater than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Forty-four patients were included, 11 (25%) of whom presented digestive intolerance. Primary outcome was assessment of the association between GCSA and the occurrence of gastric intolerance within 24 hours of the measurement. GCSA value was significantly higher in patients with upper digestive intolerance compared to those without (553 mm2 [interquartile range (IQR), 500-649 mm2] vs 970 mm2 [IQR, 777-1,047]; p < 0.001, respectively). The optimal threshold for predicting upper digestive intolerance was 720 mm2 (area under the receiver operating characteristic curve 0.86; positive predictive value 62.5%; negative predictive value 96.4%; sensibility 0.91; and specificity 0.81). Multivariate analysis (weighted by propensity score), including known risk factors, showed that GCSA above the 720 mm2 threshold was independently associated with the occurrence of upper digestive intolerance (odds ratio, 1.85; 1.37-2.49; p < 0.0002). Measurement quality was "good" (i.e., liver, aorta, superior mesenteric vein, and pancreas were all visualized) in 81% of cases. CONCLUSIONS: Measurement of GCSA by ultrasound would allow prediction of gastric intolerance in critically ill patients. This should be confirmed by a prospective score validation and interventional trials.

Updated meta-analysis on intraoperative inspired fraction of oxygen and the risk of surgical site infection in adults undergoing general and regional anesthesia.

This updated meta-analysis aims at exploring whether the use of systematic high vs low intraoperative oxygen fraction (FiO2) may decrease the incidence of postoperative surgical site infection during general (GA) or regional anesthesia (RA). PubMed, Cochrane CENTRAL, ClinicalTrials.gov databases were searched from January 1st, 1999 and July, 1st 2022, for randomized and quasi-randomized controlled trials that included patients in a high and low FiO2 groups and reported the incidence of SSI. The meta-analysis was conducted with a DerSimonian and Laird random-effects model. Thirty studies (24 for GA and 6 for RA) totaling 18,055 patients (15,871 for GA and 2184 for RA) were included. We have low-to-moderate-quality evidence that high FiO2 (mainly 80%) was not associated with a reduction of SSI incidence compared to low FiO2 (mainly 30%) in all patients (RR 0.90, 95%CI 0.79-1.03). Moderate inconsistency existed between studies (I2 = 38%). Subgroup analyses showed a moderate protective effect in patients undergoing GA (RR 0.86, 95%CI 0.75-0.99) (low level of evidence), while high FiO2 was not associated with a reduction of SSI in patients undergoing RA (RR 1.17, 95%CI 0.90-1.52) (moderate level of evidence). Sensitivity analyses restricted to patients ventilated without nitrous oxide (n = 20 studies), to patients operated from abdominal surgeries (n = 21 studies), and to patients suffering from deep SSI (n = 13 studies), all showed the absence of any significant effect of high FiO2. As a conclusion there is no compelling evidence that high FiO2 can improve postoperative patient's outcome on its own when good SSI prevention practices are properly applied. Recent well-designed and adequately powered randomized controlled trials add further weight to these results.

Surgical and perioperative management of flail chest with titanium plates: a French cohort series from a thoracic referral center.

BACKGROUND: The development of titanium claw plates has made rib osteosynthesis easy to achieve and led to a renewed interest for this surgery. We report the management of patients referred to the intensive care unit (ICU) of a referral center for surgical rib fracture fixation (SRFF) after chest trauma. METHODS: We performed a retrospective observational cohort study describing the patients' characteristics and analyzing the determinants of postoperative complications. RESULTS: From November 2013 to December 2016, 42 patients were referred to our center for SRFF: 12 patients (29%) had acute respiratory failure, 6 of whom received invasive mechanical ventilation. The Thoracic Trauma Severity Score (TTSS) was 11.0 [9-12], with 7 [5-9] broken ribs and a flail chest in 92% of cases. A postoperative complication occurred in 18 patients (43%). Five patients developed ARDS (12%). Postoperative pneumonia occurred in 11 patients (26%). Two patients died in the ICU. In multivariable analysis, the Thoracic Trauma Severity Score (TTSS) (OR = 1.89; CI 95% 1.12-3.17; p = 0.016) and the Simplified Acute Physiology Score II without age (OR = 1.17; CI 95% 1.02-1.34; p = 0.024) were independently associated with the occurrence of a postoperative complication. CONCLUSION: The TTSS score appears to be accurate for determining thoracic trauma severity. Short and long-term benefit of Surgical Rib Fracture Fixation should be assessed, particularly in non-mechanically ventilated patients.

COVID-19 acute respiratory distress syndrome promotes a specific alternative macrophage polarization.

Acute respiratory distress syndrome (ARDS) alveolar environment induced a pro-repair anti-inflammatory macrophage polarization. However, patients with coronavirus disease 2019 (COVID-19) ARDS frequently exhibit a huge lung inflammation and present pulmonary scars and fibrosis more frequently than patients with non-COVID-19 ARDS, suggesting that the COVID-19 ARDS alveolar environment may drive a more inflammatory or pro-fibrotic macrophage polarization. This study aimed to determine the effect of the COVID-19 ARDS alveolar environment on macrophage polarization. The main finding was that broncho-alveolar lavage fluids (BALF) from patients with early COVID-19 ARDS drove an alternative anti-inflammatory polarization in normal monocyte-derived macrophages; characterized by increased expressions of CD163 and CD16 mRNA (3.4 [2.7-7.2] and 4.7 [2.6-5.8] fold saline control, respectively - p = 0.02), and a secretory pattern close to that of macrophages stimulated with IL-10, with the specificity of an increased production of IL-6. This particular alternative pattern was specific to early ARDS (compared with late ARDS) and of COVID-19 ARDS (compared with moderate COVID-19). The early COVID-19 ARDS alveolar environment drives an alternative anti-inflammatory macrophage polarization with the specificity of inducing macrophage production of IL-6.

Design and Rationale of the Sevoflurane for Sedation in Acute Respiratory Distress Syndrome (SESAR) Randomized Controlled Trial.

Preclinical studies have shown that volatile anesthetics may have beneficial effects on injured lungs, and pilot clinical data support improved arterial oxygenation, attenuated inflammation, and decreased lung epithelial injury in patients with acute respiratory distress syndrome (ARDS) receiving inhaled sevoflurane compared to intravenous midazolam. Whether sevoflurane is effective in improving clinical outcomes among patients with ARDS is unknown, and the benefits and risks of inhaled sedation in ARDS require further evaluation. Here, we describe the SESAR (Sevoflurane for Sedation in ARDS) trial designed to address this question. SESAR is a two-arm, investigator-initiated, multicenter, prospective, randomized, stratified, parallel-group clinical trial with blinded outcome assessment designed to test the efficacy of sedation with sevoflurane compared to intravenous propofol in patients with moderate to severe ARDS. The primary outcome is the number of days alive and off the ventilator at 28 days, considering death as a competing event, and the key secondary outcome is 90 day survival. The planned enrollment is 700 adult participants at 37 French academic and non-academic centers. Safety and long-term outcomes will be evaluated, and biomarker measurements will help better understand mechanisms of action. The trial is funded by the French Ministry of Health, the European Society of Anaesthesiology, and Sedana Medical.

Epidural analgesia information sessions provided by anesthetic nurses: impact on satisfaction and anxiety of parturient women a prospective sequential study.

BACKGROUND: Information on epidural analgesia delivered to parturient women is frequently incomplete, making it difficult for expectant mothers to make an appropriate choice for their delivery. We assessed the impact of a multimodal information session on epidural analgesia delegated to anesthetic nurses on new-mothers' satisfaction. METHODS: We performed a prospective sequential study including parturient women who gave birth with epidural analgesia. During the first period, information on epidural analgesia was delivered by anesthetists during the scheduled anesthesia consultation, according to French standard-of-care. Then, a dedicated information session about epidural analgesia provided by anesthetic nurses was implemented. The primary endpoint was the satisfaction of women with the quality of information received. Main secondary endpoints were knowledge of women about epidural analgesia, anxiety before epidural catheter placement, and satisfaction with delivery. RESULTS: 259 and 298 women were included during the first and second periods respectively, among whom 178 and 188 were analyzed. Information on epidural analgesia delivered by anesthetic nurses was associated with improvement of new-mothers' satisfaction with information received (9 (8-10) vs. 10 (9-10) - p < 0.001). Moreover, information delivered by anesthetic nurses was associated with decreased anxiety before epidural catheter placement (4 (1-8) vs. 3 (1-6) - p = 0.006) and increased satisfaction with delivery (8 (7-10) vs. 9 (8-10) - p = 0.01). Women's knowledge on epidural analgesia was durably increased when information was delivered by anesthetic nurses compared to conventional information by anesthetists. After adjustment, the only variable associated with both new mothers' satisfaction with information and delivery was the information session taught by anesthetic nurses. CONCLUSIONS: Information sessions on epidural analgesia delivered by anesthetic nurses was associated with improved satisfaction of women with their delivery. Such information sessions may be used in maternity wards to improve new-mothers' childbirth experience.

Ultrasound assessment of the gastric content among diabetic and non-diabetic patients before elective surgery: a prospective multicenter study.

BACKGROUND: Although diabetic gastroparesis could be responsible for delayed gastric emptying, there is conflicting evidence about the volume of gastric content in diabetic patients after preoperative fasting. We hypothesized that diabetic patients had an increased gastric content before anesthesia induction despite the following of fasting recommendations. We used ultrasound assessment of gastric content to evaluate this risk. METHODS: This multicenter prospective single-blinded case-control study was conducted in three teaching University hospital in France. Our primary outcome was the comparison of increased gastric content between the two groups and was defined either by a Perlas grade 2 antrum or an antral cross-sectional area (CSA)>340 mm2. Each diabetic patient was paired with three non-diabetic control patients. Forty-two diabetic and 126 control patients were included in the study. RESULTS: Eighteen (42.9%) diabetic patients reached the primary outcome versus 28 (22.2%) in the control group (P=0.009). Diabetic patients presented less frequently with an empty stomach. Indeed, ten (23.8%) diabetic patients had a grade 0 antrum versus 71 (56.3%) in the control group (P<0.001). Twenty-four (70.6%) diabetic patients had an antral CSA<340 mm2 versus 98 (86%) in the control group (P=0.039). Overall, diabetic patients and increased gastric content were associated with an Odds Ratio, 2.63; 95% confidence interval, 1.25-5.52, P=0.009. CONCLUSIONS: Our study documents that gastric content is increased among diabetic patients compared to control patients despite following appropriate fasting guidelines.

Face-To-Face Double-Lumen Tube Intubation With the Airtraq Video Laryngoscope for Emergency Thoracic Surgery: A Case Report.

Double-lumen intubation is commonly used for thoracic surgery as it allows rapid and effective one-lung ventilation. However, it is more difficult than single-lumen tube intubation, notably in the context of emergency surgery and/or in hypoxemic patients. We report the case of a 57-year-old patient requiring emergency revision surgery after an upper right lobectomy due to postoperative pneumothorax and pleuropneumonia. As rapid lung isolation was required due to a bronchopleural fistula, rapid sequence induction and double-lumen tube intubation were performed. In addition, as the patient was hypoxemic with incomplete pre-oxygenation and too uncomfortable to tolerate the recumbent position despite high-flow oxygen, intubation was performed in face-to-face position. The patient was successfully intubated in 22 seconds and the right lung immediately isolated, allowing the surgeon to clean the pleural cavity. This is the first report of a double-lumen tube intubation in face-to-face position. The expected difficulties related to this type of intubation were successfully prevented using an Airtraq laryngoscope. Although such a strategy cannot be recommended from this one case, this report is encouraging for future studies evaluating the potential advantages of Airtraq use for double-lumen face-to-face intubation for emergency thoracic surgery.

Blood fibrocytes are associated with severity and prognosis in COVID-19 pneumonia.

Increased blood fibrocytes are associated with a poor prognosis in fibrotic lung diseases. We aimed to determine whether the percentage of circulating fibrocytes could be predictive of severity and prognosis during coronavirus disease 2019 (COVID-19) pneumonia. Blood fibrocytes were quantified by flow cytometry as CD45+/CD15-/CD34+/collagen-1+ cells in patients hospitalized for COVID-19 pneumonia. In a subgroup of patients admitted in an intensive care unit (ICU), fibrocytes were quantified in blood and bronchoalveolar lavage (BAL). Serum amyloid P (SAP), transforming growth factor-ß1 (TGF-ß1), CXCL12, CCL2, and FGF2 concentrations were measured. We included 57 patients in the hospitalized group (median age = 59 yr [23-87]) and 16 individuals as healthy controls. The median percentage of circulating fibrocytes was higher in the patients compared with the controls (3.6% [0.2-9.2] vs. 2.1% [0.9-5.1], P = 0.04). Blood fibrocyte count was lower in the six patients who died compared with the survivors (1.6% [0.2-4.4] vs. 3.7% [0.6-9.2], P = 0.02). Initial fibrocyte count was higher in patients showing a complete lung computed tomography (CT) resolution at 3 mo. Circulating fibrocyte count was decreased in the ICU group (0.8% [0.1-2.0]), whereas BAL fibrocyte count was 6.7% (2.2-15.4). Serum SAP and TGF-ß1 concentrations were increased in hospitalized patients. SAP was also increased in ICU patients. CXCL12 and CCL2 were increased in ICU patients and negatively correlated with circulating fibrocyte count. We conclude that circulating fibrocytes were increased in patients hospitalized for COVID-19 pneumonia, and a lower fibrocyte count was associated with an increased risk of death and a slower resolution of lung CT opacities.

Guidelines on enhanced recovery after pulmonary lobectomy.

OBJECTIVE: To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN: A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS: The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS: A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.