Non-opioid analgesics in adults after major surgery: systematic review with network meta-analysis of randomized trials.

BACKGROUND: Morphine, and analgesics other than morphine (AOM), are commonly used to treat postoperative pain after major surgery. However, which AOM provides the best efficacy-safety profile remains unclear. METHODS: Randomized trials of any AOM alone or any combination of AOM compared with placebo or another AOM in adults undergoing major surgery and receiving morphine patient-controlled analgesia were included in a network meta-analysis. The outcomes were morphine consumption, pain, incidence of nausea, vomiting at 24 h and severe adverse effects. RESULTS: 135 trials (13,287 patients) assessing 14 AOM alone or in combination were included. For all outcomes, comparisons with placebo were over-represented. Few trials assessed combinations of two AOM and none the combination of three or more. Network meta-analysis found morphine consumption reduction was greatest with the combination of two AOM (acetaminophen + nefopam, acetaminophen + NSAID, and tramadol + metamizol): -23.9 (95% CI -40;-7.7), -22.8 (-31.5;-14) and -19.8 (35.4;-4.2) mg per 24 h, respectively. For AOM used alone, morphine consumption reduction was greatest with α-2 agonists, NSAIDs, and COX-2 inhibitors. When considering the risk of nausea, NSAIDs, corticosteroids and α-2 agonists used alone were the most efficacious (OR 0.7 [95% CI: 0.6-0.8], 0.36 [0.18-0.79], 0.41 [0.15-.64], respectively). The paucity of severe adverse effects data did not allow assessment of efficacy-safety balance. CONCLUSIONS: A combination of aetaminophen with either an NSAID or nefopam was superior to most AOM used alone, in reducing morphine consumption. Efficacy was best with three AOM used alone (α-2 agonists, NSAIDs and COX-2 inhibitors) and least with tramadol and acetaminophen. There is insufficient trial data reporting adverse events. CLINICAL TRIAL REGISTRATION: PROSPERO: CRD42013003912.

Ultrasonographic evaluation of gastric content during labour under epidural analgesia: a prospective cohort study.

BACKGROUND: Women in labour are considered at risk of gastric content aspiration partly because the stomach remains full before delivery. Ultrasonographic measurement of antral cross-sectional area (CSA) is a validated method of gastric content assessment. Our aim was to determine gastric content volume and its changes in parturients during labour under epidural analgesia using bedside ultrasonography. METHODS: The cut-off value corresponding to an increased gastric content was determined by ultrasound measurement of antral CSA in six pregnant women in late pregnancy before and after ingestion of 250 ml of non-clear liquid. Antral CSA was then measured twice in 60 parturients who presented in spontaneous labour: when the anaesthesiologist was called for epidural analgesia catheter placement, and at full cervical dilatation. Patient-controlled epidural analgesia was performed with a solution of ropivacaine and sufentanil. RESULTS: After liquid ingestion, antral CSA (mm(2)) increased from 90 (range, 80-151) to 409 (range, 317-463). A CSA of 320 was taken as cut-off value. The feasibility rate of antral CSA determination was 96%. CSA decreased from 319 [Q1 158-Q3 469] to 203 [Q1 123-Q3 261] during labour (P=2×10(-7)). CSA was >320 in 50% of parturients at the beginning of labour vs 13% at full cervical dilatation (P=0.006). CONCLUSIONS: Bedside ultrasonographic antral CSA measurement is feasible in pregnant women during labour and easy to perform. The observed decrease in antral CSA during labour suggests that gastric motility is preserved under epidural anaesthesia. The procedure could be used to assess individual risk of gastric content aspiration during labour.

A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight.

We conducted an observational prospective multicenter study to describe the practices of mechanical ventilation, to determine the incidence of use of large intra-operative tidal volumes (≥10 ml.kg(-1) of ideal body weight) and to identify patient factors associated with this practice. Of the 2960 patients studied in 97 anaesthesia units from 49 hospitals, volume controlled mode was the most commonly used (85%). The mean (SD) tidal volume was 533 (82) ml; 7.7 (1.3) ml.kg(-1) (actual weight) and 8.8 (1.4) ml.kg(-1) (ideal body weight)). The lungs of 381 (18%) patients were ventilated with a tidal volume>10 ml.kg(-1) ideal body weight. Being female (OR 5.58 (95% CI 4.20-7.43)) and by logistic regression, underweight (OR 0.06 (95% CI 0.01-0.45)), overweight (OR 1.98 (95% CI 1.49-2.65)), obese (OR 5.02 (95% CI 3.51-7.16)), severely obese (OR 10.12 (95% CI 5.79-17.68)) and morbidly obese (OR 14.49 (95% CI 6.99-30.03)) were the significant (p ≤ 0.005) independent factors for the use of large tidal volumes during anaesthesia.

Comparison of intrathecal bupivacaine and ropivacaine with different doses of sufentanil.

BACKGROUND: Spinal bupivacaine produces a complete anaesthetic block of a longer duration than ropivacaine, which leads to a potentially increased risk of failure. A combination of sufentanil to ropivacaine may improve the block's reliability. METHODS: Sixty-four patients, scheduled for varicose vein stripping or the tension-free vaginal tape procedure, were allocated to receive double-blindly, spinal bupivacaine 10 mg (Group 1) or ropivacaine 10 mg without (Group 2) or with sufentanil 2.5 mcg (Group 3), 5 mcg (Group 4). Sensory block was tested with pinprick and motor block was evaluated with the Bromage scale until full recovery. The primary endpoint was to compare the duration of sensory block evaluated by regression to S2. RESULTS: In comparison with bupivacaine, ropivacaine produced a shorter duration sensory block (median at 68, 90 and 120 min in groups 2, 3 and 4, respectively, vs. 150 min in Group 1) and motor block (median at 90, 98 and 120 min in groups 2, 3 and 4 vs. 180 min in Group 1). Motor blockade was significantly less important in patients receiving spinal ropivacaine (median values for the Bromage scale at 3 in groups 2, 3 and 4, vs. 1 in Group 1). Pruritus was significantly more frequent in patients receiving spinal sufentanil (Groups 3 and 4 vs. Groups 1 and 2). CONCLUSION: Plain bupivacaine 10 mg has a longer recovery profile than the same dose of ropivacaine with or without sufentanil.

Performance of the Airtraq laryngoscope after failed conventional tracheal intubation: a case series.

BACKGROUND: The Airtraq, a new disposable indirect laryngoscope, was evaluated in patients with difficult intubation. METHODS: The Airtraq was used in 47 patients with predicted or unpredicted difficult intubation after failed orotracheal intubation performed by two senior anaesthesiologists with the Macintosh laryngoscope. RESULTS: Tracheal intubation with Airtraq was successful in 36 patients (80%). The Cormack and Lehane score was IIb-III in 35 patients, and IV in 12 patients, with the Macintosh laryngoscope, while Cormack and Lehane score was I-IIa in 40 patients, IIb-III in three and IV in four with Airtraq. A gum elastic bougie was used to facilitate tracheal access in one-third (11/36) of the cases. Orotracheal intubation was not possible with Airtraq in nine cases, five of whom had a pharyngeal, laryngeal or basal lingual tumour. CONCLUSION: In patients with difficult airway, following failed conventional orotracheal intubation, Airtraq allows securing the airway in 80% of cases mainly by improving glottis view. However, the Airtraq does not guarantee successful intubation in all instances, especially in case of laryngeal and/or pharyngeal obstruction.

Walking in PACU after unilateral spinal anesthesia a criteria for hospital discharge: a 100 outpatient survey.

PURPOSE: This study measured time and ability to walk in PACU after unilateral spinal anaesthesia. METHODS: Orthopaedic adult patients ASA 1-2, in the lateral decubitus position and placed on the operative side, received via a 25-gauge Whitacre needle 5 mg of 0.5% bupivacaine plus 2.5 microg of sufentanil. Lateral decubitus was maintained for 15 minutes. Time from the spinal injection to eligibility for discharge was recorded. Discharge criteria were stable hemodynamic and ability to walk without crutches. RESULTS: One hundred consecutive patients (38 females), 48 +/- 15 years-old were included. Unilateral sensory block was noted in 70% of patients. The maximum level of sensory block was at L1-T12 in 30 patients, at T11-T10 in 55 patients, at T9-T8 in 6 patients and at T7-T6 in 9. Criteria for PACU discharge were completed at 140 +/- 14 min (extremes: 55-235). All patients were discharged home uneventfully. CONCLUSION: Unilateral spinal anesthesia combining bupivacaine and sufentanil gives fast ability to walk for discharge.

Bleeding complications following peripheral regional anaesthesia in patients treated with anticoagulants or antiplatelet agents: A systematic review.

BACKGROUND: Patients on either antiplatelet or anticoagulant therapy may need procedures performed under peripheral nerve blocks in preference to general anaesthesia techniques. The risk of bleeding associated with peripheral nerve blocks under these circumstances remains unknown. This systematic review evaluates the incidence of bleeding complications following peripheral nerve blocks in patients receiving antiplatelet and/or anticoagulant medication. METHOD: All English, French and Spanish publications on peripheral nerve blocks in patients receiving antiplatelet and/or anticoagulant medication, from 1978 to 2018 from various sources including Pubmed, were reviewed. Publications on neuraxial anaesthesia (spinal or epidural) and eye blocks were excluded. RESULTS: Twenty-four articles were selected, including six observational studies and 18 case reports. Patients received antiplatelet agents only, in 4 studies, anticoagulants only in 14 studies, and both in 6 studies. In the observational studies, 80 bleeding complications (haematoma or minor bleeding at the puncture site) were identified following 9738 peripheral nerve blocks. Amongst case reports, 15 bleeding complications were noted following 50 peripheral nerve blocks. Bleeding complications were reported mostly with lumbar plexus blocks (1 requirement for blood transfusion, 1 catheter embolization, 1 surgical exploration and 1 death). The overall estimate of the incidence of bleeding complications was 0.82% (0.64%-1.0%). CONCLUSION: This systematic review found that bleeding complications following peripheral nerve blocks were rare in patients receiving antiplatelet and/or anticoagulant medication.

Meta-analysis of intravenous lidocaine and postoperative recovery after abdominal surgery.

BACKGROUND: Continuous intravenous administration of lidocaine may decrease the duration of ileus and pain after abdominal surgery. METHODS: Three databases (Medline, Embase and the Cochrane Controlled Trials Register) were searched to retrieve randomized controlled trials comparing continuous intravenous lidocaine infusion during and after abdominal surgery with placebo. Study design was scored using the Oxford Quality Score based on randomization, double-blinding and follow-up. Outcome measures were duration of ileus, length of hospital stay, postoperative pain, and incidence of nausea and vomiting. RESULTS: Eight trials were selected. A total of 161 patients received intravenous lidocaine, with 159 controls. Intravenous lidocaine administration decreased the duration of ileus (weighted mean difference (WMD) - 8.36 h; P < 0.001), length of hospital stay (WMD - 0.84 days; P = 0.002), postoperative pain intensity at 24 h after operation on a 0-100-mm visual analogue scale (WMD - 5.93 mm; P = 0.002), and the incidence of nausea and vomiting (odds ratio 0.39; P = 0.006). CONCLUSION: Continuous intravenous administration of lidocaine during and after abdominal surgery improves patient rehabilitation and shortens hospital stay.

Pharyngo-laryngeal discomfort after breast surgery: comparison between orotracheal intubation and laryngeal mask.

Sore throat and dysphonia are a significant source of postoperative discomfort for patients scheduled for breast surgery who have been intubated for general anaesthesia. The aim of this study was to compare the incidence of postoperative pharyngo-laryngeal pain and dysphonia in the use of the laryngeal mask airway (LMA) or tracheal intubation in these patients. In a prospective, double-blind, randomised clinical trial we studied 53 women undergoing elective breast surgery to test the hypothesis that the use of the LMA could reduce the incidence of pharyngo-laryngeal morbidity compared with tracheal intubation. Postoperative sore throat and hoarseness were assessed at 6 and 24h by a standardised interview. The incidence of postoperative sore throat was significantly higher in the case of tracheal intubation at 6h (74% vs. 27%, p=0.0003) and at 24h (27% vs. 0%, p=0.004). The incidence of hoarseness was significantly higher in the tracheal intubation group than in the LMA group at 6h after surgery (40% vs. 15%, p=0.04), but not at 24h. Compared with tracheal intubation, the use of the LMA is associated with a lower incidence of postoperative sore throat and hoarseness and may contribute for improving patient comfort after breast surgery.

Effect of prophylactic 5-HT3 receptor antagonists on pruritus induced by neuraxial opioids: a quantitative systematic review.

Pruritus is a frequent adverse event observed after neuraxial administration of opioids. Central 5-hydroxytryptamine subtype 3 (5-HT3) receptors may be activated in this process. This systematic review aimed to evaluate the efficacy of prophylactic 5-HT3 receptor antagonists on neuraxial opioid-induced pruritus. We searched Medline, Embase, and Cochrane Collaboration Library databases. Studies were evaluated with the Oxford Validity Scale. Studies with a score of 3 or more and reporting prophylactic administration of 5-HT3 receptor antagonists vs placebo were included. Fifteen randomized double-blind controlled trials (n=1337) were selected. 5-HT3 antagonists (n=775) significantly reduced pruritus [odds ratio (OR) 0.44 (95% confidence interval, 95% CI, 0.29-0.68), P=0.0002, number-needed-to-treat (NNT) 6 (95% CI, 4-14)], the treatment request for pruritus [OR 0.58 (95% CI, 0.43-0.78), P=0.0003, NNT 10 (95% CI, 7-20)], the intensity of pruritus [weighted mean difference (WMD) -0.35 (95% CI, -0.59 to -0.10), P=0.007], the incidence and the intensity of postoperative nausea and vomiting (PONV), and the need of rescue treatment [respectively, Peto odds ratio (Peto OR) 0.43 (95% CI, 0.31-0.58), P<0.00001, NNT 7 (95% CI, 6-10); WMD -0.12 (95% CI, -0.24 to 0.00), P=0.05 and OR 0.42 (95% CI, 0.20-0.86), P=0.02, NNT 8 (95% CI, 5-35)]. However, the funnel plot was asymmetric, suggesting a risk of publication bias. 5-HT3 receptor antagonists may be an effective strategy in preventing neuraxial opioid-induced pruritus and PONV. Further large randomized controlled trials are required to confirm these findings.

[Anaesthesia and critical care for scheduled infrarenal abdominal aortic aneurysm surgery]. / Anesthésie et réanimation pour chirurgie réglée de l'anévrisme de l'aorte abdominale.

OBJECTIVES: Patient scheduled for infrarenal abdominal aortic aneurysm surgery carries a high risk of cardiac or respiratory comorbidity. To outline the perioperative management for these patients. METHODS: Review of the literature using MesH Terms "abdominal aortic aneurysm", "anesthesia", "analgesia" "critical care" and/or "surgery" in Medline database. RESULTS: Cardiac preoperative evaluation and management have recently been reviewed. Intermediate and high-risk patients should undergo non-invasive cardiac testing to decide between a preoperative medical strategy (using betablocker+/-statin and aspirin) and an interventional strategy (coronary angioplasty or cardiac surgery). Perioperative myocardial ischaemia should also be investigated by clinical, electrocardiographic and biologic monitoring such as plasmatic troponin Ic dosage. Specific score could also assess the respiratory failure risk preoperatively. Epidural analgesia decreases this risk. There is no evidence that a pharmacological treatment decreases the incidence of acute renal failure after aortic surgery. Endovascular repair is actually recommended for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair.

[Haemoptysis after anesthesia]. / Hémoptysie au réveil anesthésique.

Postobstructive pulmonary oedema is a complication after extubation that occurs rarely . It can be associated with haemoptysis. We report two cases of haemoptysis occuring in ASA 1 otherwise healthy patients who underwent uncomplicated anaesthesia. Understanding of the mechanism and prompt treatment lead to rapid recovery of this dramatic complication.

[Effectiveness of analgesic techniques after breast surgery: a meta-analysis]. / Efficacité des techniques d'analgésie locorégionale après chirurgie du sein: une méta-analyse.

OBJECTIVE: To evaluate the effectiveness of locoregional analgesic techniques (thoracic paravertebral block (TPVB), wound infiltration (WI)) after breast surgery. STUDY DESIGN: Meta-analysis. METHODS: Searches of Medline and Cochrane were performed using the search terms "breast surgery" and "local anaesthetics" and "infiltration" or "paravertebral block". Manual searches were also performed. Two independent investigators assessed the publications and extracted the data. Inclusion criteria were randomised controlled trials that evaluated effectiveness of single-injection TPVB or WI with local anaesthetics after breast surgery. Postoperative pain scores evaluated by visual analogic scale (VAS) during the first six hours (H6), at twelve hours (H12) and incidence of postoperative nausea and vomiting (PONV) were collected. RESULTS: Nine studies met inclusion criteria with five trials that evaluated paravertebral block (N=253) and 4 studies that evaluated wound infiltration (N=174). TPVB decreased significantly VAS at H6 (Weighted mean difference (WMD)=-18 [-5;-32] ; P=0.007) and at H12 (WMD=-12[-20;-4] ; P=0.001) and the risk of PONV (relative risk=0.39 [0.26; 0.57] ; P<0.00001). WI did not decrease significantly VAS for postoperative pain and PONV. CONCLUSION: Single injection TPVB in contrast to WI is effective for analgesia after breast surgery and decreases PONV.

[Prevention of venous thromboembolism in surgery and obstetrics]. / Prévention de la maladie thromboembolique veineuse périopératoire et obstétricale.

The French Society of anaesthesiology and intensive care has chosen a high level methodology to issue professional Recommendations on perioperative and obstetrical venous thromboembolism prophylaxis. In addition with a short review on mechanical and pharmacological prophylaxis, all surgical and obstetrical settings have been studied. The initiation and duration of prophylaxis have been particularly debated in close relation with the level of surgical risk. A large group of experts has been involved in this process. More than 150 other experts have participated in the reading process. Didactic tables have been added to help the prescription.

[Prophylaxis of thromboembolic events during urologic surgery]. / Prévention de la maladie thromboembolique en chirurgie urologique.

Few scientific evidences are available in the literature, and the methodologic quality of the studies is often under average. Nevertheless, the conclusions are the following. Nephrectomy, renal transplantation, open surgery of the lower urinary tract and lumbar or pelvic lymph nodes dissection are at high risk for thromboembolic events. Other open or endoscopic urological procedures are at low risk. The laparoscopic approach doesn't change the risk associated with the procedure itself. Thromboprophylaxis is recommended in high-risk procedures. There was no evidence to recommend starting the prophylaxis before more than after the procedure. The use of low molecular weight heparin is recommended for prophylaxis. It can be associated with compressive stockings. It is recommended to treat for around seven days after the procedure. In case of cancer surgery, prophylaxis could be needed for four to six weeks.

[Increase in bispectral index induced by antihyperalgesic dose of ketamine]. / La kétamine à dose antihyperalgésique augmente l'index bispectral.

We report two cases of sudden increase in Bispectral Index (BIS) after the injection of low-dose ketamine for the prevention of postoperative hyperalgesia. The two patients were anaesthetised with a continuous infusion of remifentanil associated with propofol for one and isoflurane for the other. Changes in BIS occurred while the two patients were in a stable phase of surgery (beginning of parietal closure and suture of an anastomosis) and had a stable target concentration of anaesthetic agents. No others signs of awakening were observed. The BIS value returned progressively to 40-50 despite no increase in target concentration. None of the patients complained of intra-operative recall.

[Diagnosis of a persistent left superior vena cava in the operating room during a central venous catheterization]. / Diagnostic d'une veine cave supérieure gauche persistante au bloc opératoire lors d'un cathétérisme veineux central.

A 2-year-old boy was admitted for surgical excision of a hepatoblastome. A central venous catheter was inserted by a subclavian approach, without difficulty. The chest radiograph showed the catheter positioned along the left heart border. The diagnosis of persistent left superior vena cava was suspected after analysis of the central venous pressure curve. An postoperative chest X-ray confirmed the diagnosis. The catheter was maintained for five days without any complication.

[Epidemiology of cerebral perioperative vascular accidents]. / Épidémiologie des accidents vasculaires cérébraux périopératoires.

OBJECTIVES: Stroke is a well-described postoperative complication, after carotid and cardiac surgery. On the contrary, few studies are available concerning postoperative stroke in general non-cardiac non-carotid surgery. The high morbid-mortality of stroke justifies an extended analysis of recent literature. ARTICLE TYPE: Systematic review. DATA SOURCES: Firstly, Medline and Ovid databases using combination of stroke, cardiac surgery, carotid surgery, general non-cardiac non-carotid surgery as keywords; secondly, national and European epidemiologic databases; thirdly, expert and French health agency recommendations; lastly, reference book chapters. RESULTS: In cardiac surgery, with an incidence varying from 1.2 to 10% according to procedure complexity, stroke occurs peroperatively in 50% of cases and during the first 48 postoperative hours for the others. The incidence of stroke after carotid surgery is 1 to 20% according to the technique used as well as operator skills. Postoperative stroke is a rare (0.15% as mean, extremes around 0.02 to 1%) complication in general surgery, it occurs generally after the 24-48th postoperative hours, exceptional peroperatively, and 40% of them occurring in the first postoperative week. It concerned mainly aged patient in high-risk surgeries (hip fracture, vascular surgery). Postoperative stroke was associated to an increase in perioperative mortality in comparison to non-postoperative stroke operated patients. CONCLUSION: Postoperative stroke is a quality marker of the surgical teams' skill and has specific onset time and induces an increase of postoperative mortality.