Opioid-free anaesthesia with dexmedetomidine and lidocaine versus remifentanil-based anaesthesia in cardiac surgery: study protocol of a French randomised, multicentre and single-blinded OFACS trial.

INTRODUCTION: Intraoperative opioids have been used for decades to reduce negative responses to nociception. However, opioids may have several, and sometimes serious, adverse effects. Cardiac surgery exposes patients to a high risk of postoperative complications, some of which are common to those caused by opioids: acute respiratory failure, postoperative cognitive dysfunction, postoperative ileus (POI) or death. An opioid-free anaesthesia (OFA) strategy, based on the use of dexmedetomidine and lidocaine, may limit these adverse effects, but no randomised trials on this issue have been published in cardiac surgery.We hypothesised that OFA versus opioid-based anaesthesia (OBA) may reduce the incidence of major opioid-related complications after cardiac surgery. METHODS AND ANALYSIS: Multicentre, randomised, parallel and single-blinded clinical trial in four cardiac surgical centres in France, including 268 patients scheduled for coronary artery bypass grafting under cardiac bypass, with or without aortic valve replacement. Patients will be randomised to either a control OBA protocol using remifentanil or an OFA protocol using dexmedetomidine/lidocaine. The primary composite endpoint is the occurrence of at least one of the following: (1) postoperative cognitive disorder evaluated by the Confusion Assessment Method for the Intensive Care Unit test, (2) POI, (3) acute respiratory distress or (4) death within the first 48 postoperative hours. Secondary endpoints are postoperative pain, morphine consumption, nausea-vomiting, shock, acute kidney injury, atrioventricular block, pneumonia and length of hospital stay. ETHICS AND DISSEMINATION: This trial has been approved by an independent ethics committee (Comité de Protection des Personnes Ouest III-Angers on 23 February 2021). Results will be submitted in international journals for peer reviewing. TRIAL REGISTRATION NUMBER: NCT04940689, EudraCT 2020-002126-90.

Pre-operative maintenance of angiotensin-converting enzyme inhibitors is not associated with acute kidney injury in cardiac surgery patients with cardio-pulmonary bypass: a propensity-matched multicentric analysis.

Objective: We investigated the effects of the maintenance of angiotensin-converting enzyme inhibitors (ACE inhibitors) the day of the surgery on the incidence of postoperative acute kidney injury (AKI) and cardiac events in patients undergoing cardiac surgery. Methods: We performed a multicentric observational study with propensity matching on 1,072 patients treated with ACE inhibitors. We collected their baseline demographic data, comorbidities, and operative and postoperative outcomes. AKI was defined by KDIGO (Kidney Disease: Improving Global Outcome). Results: Maintenance of an ACE inhibitor was not associated with an increased risk of AKI (OR: 1.215 (CI95%:0.657-2.24), p = 0.843, 71 patients (25.1%) vs. 68 patients (24%)). Multivariate logistic regression and sensitive analysis did not demonstrate any association between ACE inhibitor maintenance and AKI, following cardiac surgery (OR: 1.03 (CI95%:0.81-1.3)). No statistically significant difference occurs in terms of incidence of cardiogenic shock (OR: 1.315 (CI95%:0.620-2.786)), stroke (OR: 3.313 (CI95%:0.356-27.523)), vasoplegia (OR: 0.741 (CI95%:0.419-1.319)), postoperative atrial fibrillation (OR: 1.710 (CI95%:0.936-3.122)), or mortality (OR: 2.989 (CI95%:0.343-26.034)). ICU and hospital length of stays did not differ (3 [2; 5] vs. 3 [2; 5] days, p = 0.963 and 9.5 [8; 12] vs. 10 [8; 14] days, p = 0.638). Conclusion: Our study revealed that maintenance of ACE inhibitors on the day of the surgery was not associated with increased postoperative AKI. ACE inhibitor maintenance was also not associated with an increased rate of postoperative major cardiovascular events (arterial hypotension, cardiogenic shock, vasopressors use, stroke and death).

Effect of opioid-free anesthesia on post-operative period in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy: a propensity score matched study.

BACKGROUND: Postoperative pain after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is important. It appears essential to reduce postoperative pain and morphine consumption. METHODS: Retrospective study in a university hospital comparing patient benefiting from CRS-HIPEC under opioid-free anesthesia (OFA; dexmedetomidine) to those anesthetized with opioid anesthesia (OA; remifentanil) using a propensity score matching method. The main objective was the impact of OFA on postoperative morphine consumption in the first 24 h after surgery. RESULTS: 102 patients were included, matching on the propensity score allowed selecting 34 unique pairs analyzed. Morphine consumption was lower in the OFA group than in the OA group (3.0 [0.00-11.0] mg/24 h vs. 13.0 [2.5-25.0] mg/24 h; p = 0.02). In multivariable analysis, OFA was associated with a reduction of 7.2 [0.5-13.9] mg of postoperative morphine (p = 0.04). The rate of renal failure with a KDIGO-score > 1 was lower in the OFA group than in the OA group (12% vs. 38%; p = 0.01). There was no difference between groups concerning length of surgery/anesthesia, norepinephrine infusion, volume of fluid therapy, post-operative complications, rehospitalization or ICU readmission within 90 days, mortality, and postoperative rehabilitation. CONCLUSION: Our results suggest that OFA for CRS-HIPEC patients appears safe and is associated with less postoperative morphine use and acute kidney injury.

Overview of the current use of levosimendan in France: a prospective observational cohort study.

BACKGROUND: Following the results of randomized controlled trials on levosimendan, French health authorities requested an update of the current use and side-effects of this medication on a national scale. METHOD: The France-LEVO registry was a prospective observational cohort study reflecting the indications, dosing regimens, and side-effects of levosimendan, as well as patient outcomes over a year. RESULTS: The patients included (n = 602) represented 29.6% of the national yearly use of levosimendan in France. They were treated for cardiogenic shock (n = 250, 41.5%), decompensated heart failure (n = 127, 21.1%), cardiac surgery-related low cardiac output prophylaxis and/or treatment (n = 86, 14.3%), and weaning from veno-arterial extracorporeal membrane oxygenation (n = 82, 13.6%). They received 0.18 ± 0.07 µg/kg/min levosimendan over 26 ± 8 h. An initial bolus was administered in 45 patients (7.5%), 103 (17.1%) received repeated infusions, and 461 (76.6%) received inotropes and or vasoactive agents concomitantly. Hypotension was reported in 218 patients (36.2%), atrial fibrillation in 85 (14.1%), and serious adverse events in 17 (2.8%). 136 patients (22.6%) died in hospital, and 26 (4.3%) during the 90-day follow-up. CONCLUSIONS: We observed that levosimendan was used in accordance with recent recommendations by French physicians. Hypotension and atrial fibrillation remained the most frequent side-effects, while serious adverse event potentially attributable to levosimendan were infrequent. The results suggest that this medication was safe and potentially associated with some benefit in the population studied.

Comparison of landiolol and amiodarone for the treatment of new-onset atrial fibrillation after cardiac surgery (FAAC) trial: study protocol for a randomized controlled trial.

BACKGROUND: Postoperative atrial fibrillation (PoAF) after cardiac surgery has a high incidence of 30%, but its management is controversial. Two strategies are recommended without evidence of a superiority of one against the other: rate control with beta-blocker or rhythm control with amiodarone. Landiolol is a new-generation beta-blocker with fast onset and short half-life. One retrospective, single-center study compared landiolol to amiodarone for PoAF after cardiac surgery with a better hemodynamic stability and a higher rate of reduction to sinus rhythm with landiolol, justifying the need for a multicenter randomized controlled trial. Our aim is to compare landiolol to amiodarone in the setting of PoAF after cardiac surgery with the hypothesis of a higher rate of reduction to sinus rhythm with landiolol during the 48 h after the first episode of POAF. METHODS: The FAAC trial is a multicenter single-blind two parallel-arm randomized study, which planned to include 350 patients with a first episode of PoAF following cardiac surgery. The duration of the study is 2 years. The patients are randomized in two arms: a landiolol group and an amiodarone group. Randomization (Ennov Clinical®) is performed by the anesthesiologist in charge of the patient if PoAF is persistent for at least 30 min after correction of hypovolemia, dyskalemia, and absence of pericardial effusion on a transthoracic echocardiography done at bedside. Our hypothesis is an increase of the percentage of patients in sinus rhythm from 70 to 85% with landiolol in less than 48 h after onset of PoAF (alpha risk = 5%, power = 90%, bilateral test). DISCUSSION: The FAAC trial was approved by the Ethics Committee of EST III with approval number 19.05.08. The FAAC trial is the first randomized controlled trial comparing landiolol to amiodarone for PoAF after cardiac surgery. In case of higher rate of reduction with landiolol, this beta-blocker could be the drug of choice used in this context as to reduce the need for anticoagulant therapy and reduce the risk of complications of anticoagulant therapy for patients with a first episode of postoperative atrial fibrillation after cardiac surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT04223739. Registered on January 10, 2020.

Erector Spinae Plane Block versus Paravertebral Block after Thoracic Surgery for Lung Cancer: A Propensity Score Study.

INTRODUCTION: The prevention of respiratory complications is a major issue after thoracic surgery for lung cancer, and requires adequate post-operative pain management. The erector spinae plane block (ESPB) may decrease post-operative pain. The objective of this study was to evaluate the impact of ESPB on pain after video or robot-assisted thoracic surgery (VATS or RATS). METHODS: The main outcome of this retrospective study with a propensity score analysis (PSA) was to compare the post-operative pain at 24 h at rest and at cough between a group that received ESPB and a group that received paravertebral block (PVB). Post-operative morphine consumption at 24 h and complications were also assessed. RESULTS: One hundred and seven patients were included: 54 in the ESPB group and 53 in the PVB group. The post-operative median pain score at rest and cough was lower in the ESPB group compared to the PVB group at 24 h (respectively, at rest 2 [1; 3.5] vs. 2 [0; 4], p = 0.0181, with PSA; ESPB -0.80 [-1.50; -0.10], p = 0.0255, and at cough (4 [3; 6] vs. 5 [4; 6], p = 0.0261, with PSA; ESPB -1.48 [-2.65; -0.31], p = 0.0135). There were no differences between groups concerning post-operative morphine consumption at 24 h and respiratory complications. CONCLUSIONS: Our results suggest that ESPB is associated with less post-operative pain at 24 h than PVB after VATS or RATS for lung cancer. Furthermore, ESPB is an acceptable and safe alternative compared to PVB.

Paravertebral block combined with serratus anterior plane block after video-assisted thoracic surgery: a prospective randomized controlled trial.

OBJECTIVES: Adequate pain management after thoracoscopic surgery is a major issue in the prevention of respiratory complications. The combination of the paravertebral block (PVB) with the serratus anterior plane block (SAPB) may decrease postoperative pain. The objective of this study was to evaluate the impact of the combination of PVB and SAPB on the consumption of morphine and pain after video- or robot-assisted thoracic surgery. METHODS: The main objective of this randomized controlled trial was to compare the cumulative postoperative morphine consumption at 24 h between a group having PVB (PVB group) and a group having PVB and SAPB (PV-SAPB group). Postoperative pain at 6 and 24 h and morphine-related complications were also assessed. RESULTS: A total of 112 patients were included with 56 in each group. There was no difference in median cumulative morphine consumption at 24 h between the 2 groups (P = 0.1640). At 6 h, the median postoperative pain was higher in the PVB group compared to the PV-SAPB group (3 [0; 4] vs 2 [0; 3], P = 0.0231). There were no differences between the 2 groups for pain at 24 h and morphine-related complications. CONCLUSIONS: We did not find any difference in morphine consumption between the 2 groups. Our results suggest that the combination of PVB and SAPB for video-assisted thoracic surgery or robot-assisted thoracic surgery is safe effective and reliable and could be an alternative to PVB alone in certain indications.

Perioperative individualized hemodynamic optimization according to baseline mean arterial pressure in cardiac surgery patients: Rationale and design of the OPTIPAM randomized trial.

BACKGROUND: Postoperative morbidity and mortality after cardiac surgery with cardiopulmonary bypass (CPB) remain high despite recent advances in both anesthesia and perioperative management. Among modifiable risk factors for postoperative complications, optimal arterial pressure during and after surgery has been under debate for years. Recent data suggest that optimizing arterial pressure to the baseline of the patient may improve outcomes. We hypothesize that optimizing the mean arterial pressure (MAP) to the baseline MAP of the patient during cardiac surgery with CPB and during the first 24 hours postoperatively may improve outcomes. STUDY DESIGN: The OPTIPAM trial (NCT05403697) will be a multicenter, randomized, open-label controlled trial testing the superiority of optimized MAP management as compared with a MAP of 65 mm Hg or more during both the intraoperative and postoperative periods in 1,100 patients scheduled for cardiac surgery with CPB. The primary composite end point is the occurrence of acute kidney injury, neurological complications including stroke or postoperative delirium, and death. The secondary end points are hospital and intensive care unit lengths of stay, Day 7 and Day 90 mortality, postoperative cognitive dysfunction on Day 7 and Day 90, and quality of life at Day 7 and Day 90. Two interim analyses will assess the safety of the intervention. CONCLUSION: The OPTIPAM trial will assess the effectiveness of an individualized target of mean arterial pressure in cardiac surgery with CPB in reducing postoperative morbidity. CLINICAL TRIAL REGISTRATION: NCT05403697.

Point-of-Care Viscoelastic Hemostatic Assays in Cardiac Surgery Patients: Comparison of Thromboelastography 6S, Thromboelastometry Sigma, and Quantra.

OBJECTIVES: Viscoelastic tests allow a reduction in blood product transfusion. Three modern devices are currently available (rotational thromboelastometry [ROTEM] sigma, thromboelastography [TEG] 6S, and Quantra). No study has compared the performances of these 3 devices simultaneously. DESIGN: An observational, nonrandomized cohort study. SETTING: A single-center of cardiac surgery in a university hospital. PARTICIPANTS: A total of 30 consecutive measurements from at least 10 adult patients presenting significant bleeding in the intensive care unit after cardiac surgery INTERVENTION: Viscoelastic tests using ROTEM sigma, TEG 6S, and Quantra were performed concomitantly with conventional coagulation measurements MEASUREMENTS AND MAIN RESULTS: The authors included 16 patients with 31 blood samples. After the exclusion of missing values, 27 samples were analyzed. Correlation with platelet count was as follows: ROTEM, r = 0.84 [0.66-0.93], p < 0.0001; Quantra, r = 0.83 [0.64-0.92], p < 0.0001; TEG 6S, r = 0.64 [0.29-0.83], p = 0.001. Correlation with fibrinogen (Clauss assay) was as follows: ROTEM, r = 0.85 [0.68-0.93], p < 0.0001; Quantra, r = 0.88 [0.74-0.95], p < 0.0001; TEG 6S, r = 0.79 [0.55-0.91], p < 0.0001. No difference was observed for the detection of residual circulating heparin (anti-Xa activity >0.1), with 87% of correct identification for Quantra and 80% for both ROTEM and TEG 6S (p = 0.3). Time to first results after the beginning of the test was shorter for Quantra than ROTEM and TEG 6S (136 [126-152] seconds v 205 [176-221] seconds, p = 0.003 and v 450 [372-516] seconds, p < 0.0001 respectively). CONCLUSION: ROTEM sigma, TEG 6S, and Quantra performed similarly for exploring platelet count or residual circulating heparin. Thromboelastography 6S presented a weaker correlation with fibrinogen Clauss.

Epidemiology, risk factors and outcomes of norepinephrine use in cardiac surgery with cardiopulmonary bypass: a multicentric prospective study.

BACKGROUND: The present study was designed to describe the prevalence of norepinephrine use, the factors associated with its use, and the incidence of postoperative complications according to norepinephrine use, in patients undergoing cardiac surgery with cardiopulmonary bypass. METHOD: We performed a prospective, multicenter, observational study in 4 University-affiliated medico-surgical cardiovascular units. We analyzed all patients treated with cardiac surgery after excluding pre-ECMO surgery, LVAD implantation, heart transplantation and intra-operative hemorrhage. RESULTS: Of 9316 patients screened during the study period, 2862 were included and 2510 were analyzed. Among them, 1549 (61%) were treated with norepinephrine with a median maximal dose of 0.11 [0.06-0.2] µg.kg-1.min-1 and a median duration of 10 h [2-24]. Norepinephrine was most often started in the operating room before cardiopulmonary bypass. The multiple regression logistic analysis identified several modifiable (haematocrit, maintenance of beta-blocker, cardiopulmonary bypass time, glucose-insulin-potassium, Custodiol cardioplegia, Delnido cardioplegia, and fibrinogen transfusion) and non-modifiable factors (age, ASA score, chronic high blood pressure, coronary disease, dyslipidemia, right ventricular dysfunction, left ventricular dysfunction, active endocarditis, and valvular aortic surgery) associated with norepinephrine use. Mortality, morbidity (neurological and renal complications, death) and length of stay in the ICU were higher in patients treated with norepinephrine. CONCLUSION: Norepinephrine is often used in cardiac surgical patients but for <24 h with a low dose. Many preoperative and surgical factors are associated with norepinephrine use. Patients supported by norepinephrine have a higher incidence of major postoperative events.

Post-cardiac surgery fungal mediastinitis: clinical features, pathogens and outcome.

OBJECTIVES: The occurrence of mediastinitis after cardiac surgery remains a rare and severe complication associated with poor outcomes. Whereas bacterial mediastinitis have been largely described, little is known about their fungal etiologies. We report incidence, characteristics and outcome of post-cardiac surgery fungal mediastinitis. METHODS: Multicenter retrospective study among 10 intensive care units (ICU) in France and Belgium of proven cases of fungal mediastinitis after cardiac surgery (2009-2019). RESULTS: Among 73,688 cardiac surgery procedures, 40 patients developed fungal mediastinitis. Five were supported with left ventricular assist device and five with veno-arterial extracorporeal membrane oxygenation before initial surgery. Twelve patients received prior heart transplantation. Interval between initial surgery and mediastinitis was 38 [17-61] days. Only half of the patients showed local signs of infection. Septic shock was uncommon at diagnosis (12.5%). Forty-three fungal strains were identified: Candida spp. (34 patients), Trichosporon spp. (5 patients) and Aspergillus spp. (4 patients). Hospital mortality was 58%. Survivors were younger (59 [43-65] vs. 65 [61-73] yo; p = 0.013), had lower body mass index (24 [20-26] vs. 30 [24-32] kg/m2; p = 0.028) and lower Simplified Acute Physiology Score II score at ICU admission (37 [28-40] vs. 54 [34-61]; p = 0.012). CONCLUSION: Fungal mediastinitis is a very rare complication after cardiac surgery, associated with a high mortality rate. This entity should be suspected in patients with a smoldering infectious postoperative course, especially those supported with short- or long-term invasive cardiac support devices, or following heart transplantation.

Effect of mechanical ventilation during cardiopulmonary bypass on end-expiratory lung volume in the perioperative period of cardiac surgery: an observational study.

BACKGROUND: Many studies explored the impact of ventilation during cardiopulmonary bypass (CPB) period with conflicting results. Functional residual capacity or End Expiratory Lung Volume (EELV) may be disturbed after cardiac surgery but the specific effects of CPB have not been studied. Our objective was to compare the effect of two ventilation strategies during CPB on EELV. METHODS: Observational single center study in a tertiary teaching hospital. Adult patients undergoing on-pump cardiac surgery by sternotomy were included. Maintenance of ventilation during CPB was left to the discretion of the medical team, with division between "ventilated" and "non-ventilated" groups afterwards. Iterative intra and postoperative measurements of EELV were carried out by nitrogen washin-washout technique. Main endpoint was EELV at the end of surgery. Secondary endpoints were EELV one hour after ICU admission, PaO2/FiO2 ratio, driving pressure, duration of mechanical ventilation and post-operative pulmonary complications. RESULTS: Forty consecutive patients were included, 20 in each group. EELV was not significantly different between the ventilated versus non-ventilated groups at the end of surgery (1796 ± 586 mL vs. 1844 ± 524 mL, p = 1) and one hour after ICU admission (2095 ± 562 vs. 2045 ± 476 mL, p = 1). No significant difference between the two groups was observed on PaO2/FiO2 ratio (end of surgery: 339 ± 149 vs. 304 ± 131, p = 0.8; one hour after ICU: 324 ± 115 vs. 329 ± 124, p = 1), driving pressure (end of surgery: 7 ± 1 vs. 8 ± 1 cmH2O, p = 0.3; one hour after ICU: 9 ± 3 vs. 9 ± 3 cmH2O), duration of mechanical ventilation (5.5 ± 4.8 vs 8.2 ± 10.0 h, p = 0.5), need postoperative respiratory support (2 vs. 1, p = 1), occurrence of pneumopathy (2 vs. 0, p = 0.5) and radiographic atelectasis (7 vs. 8, p = 1). CONCLUSION: No significant difference was observed in EELV after cardiac surgery between not ventilated and ventilated patients during CPB.

Incidence of Postoperative Pain at 7 Days After Day Surgery Reported Using a Text Messaging Platform: Retrospective Observational Study.

BACKGROUND: The most frequent complication observed after ambulatory surgery is acute postoperative pain. OBJECTIVE: The purpose of this study was to evaluate the late incidence of postoperative pain at 7 days after day surgery. METHODS: We retrospectively included patients who underwent day surgery under general or regional anesthesia and those who underwent local anesthesia in Rouen University Hospital from January 2018 to February 2020. Data collected were moderate-to-severe pain reports defined as numeric rating scale (NRS)>3/10 at 1 day (secondary end point) and 7 days (primary end point) after surgery. These data were collected using a semi-intelligent SMS text messaging platform to follow up with the patient at home after ambulatory surgery. Univariate and multivariate analyses were performed to analyze the risk factors for pain. RESULTS: We analyzed 6099 patients. On the day after the surgery, 5.2% (318/6099) of the patients presented with moderate-to-severe pain: 5.9% (248/4187) in the general or regional anesthesia group and 3.7% (70/1912) in the local anesthesia group. At 7 days after the surgery, 18.6% (1135/6099) of the patients presented with moderate-to-severe pain, including 21.3% (892/4187) of the patients in the general or regional anesthesia group and 12.7% (243/1912) of the patients in the local anesthesia group. General surgery (odds ratio [OR] 1.54, 95% CI 1.23-1.92; P<.01) and orthopedic surgery (OR 1.66, 95% CI 1.42-1.94; P<.01) were associated with more late postoperative pain risk. Male gender (OR 0.66, 95% CI 0.57-0.76; P<.01), ophthalmology surgery (OR 0.51, 95% CI 0.42-0.62; P<.01), and gynecologic surgery (OR 0.67, 95% CI 0.50-0.88; P=.01) were associated with less late postoperative pain risk. The rate of emergency consultation or rehospitalization at 7 days after the surgery was 11.1% (679/6099). Late postoperative pain (OR 2.54, 95% CI 1.98-3.32; P<.001), general surgery (OR 2.15, 95% CI 1.65-2.81; P<.001), and urology surgery (OR 1.62, 95% CI 1.06-2.43; P=.02) increased the risk of emergency consultation or rehospitalization. Orthopedic surgery (OR 0.79, 95% CI 0.63-0.99; P=.04) and electroconvulsive therapy (OR 0.43, 95% CI 0.27-0.65; P<.001) were associated with less rates of emergency consultation or rehospitalization. CONCLUSIONS: Our study shows that postoperative pain at 7 days after ambulatory surgery was reported in more than 18% of the cases, which was also associated with an increase in the emergency consultation or rehospitalization rates.

Reliability of the Minto model for target-controlled infusion of remifentanil during cardiac surgery with cardiopulmonary bypass.

BACKGROUND: The Minto pharmacokinetic model is used for target-controlled infusion of remifentanil. The reliability of this model has never been evaluated during normothermic cardiac surgery with cardiopulmonary bypass (CPB). The aim of this study was to assess the predictive performance of the model during CPB to determine its reliability during cardiac surgery. METHODS: This was a single-centre observational study. Arterial blood samples were drawn at five time points: T1, after tracheal intubation; T2, immediately before CPB; T3, 10 min after starting CPB; T4, 45 min after starting CPB; T5, 10 min after weaning off CPB. Prediction error (PE) and absolute prediction error (APE) were calculated for each sample and used to determine median prediction error (MDPE) and median absolute prediction error (MDAPE) per patient. Risk factors for APE >30% were assessed using multivariable analysis. Results are presented as medians with inter-quartile ranges. RESULTS: Fifty-eight patients with 283 blood samples (110 during CPB) were included. In the pre-CPB period, MDPE and MDAPE were -17.3 [-32.9 to 2.3] and 24.6 [12-37.7]%, whereas during CPB, they were -1.8 [-15.6 to 11.1] and 14.0 [6.74-27.1]%, respectively. There was no statistically significant difference between measured and predicted remifentanil plasma concentrations during CPB. Age, preoperative albumin concentrations, temperature, and haemodilution were not independently associated with MDAPE >30%. CONCLUSIONS: The Minto model accurately predicts plasma remifentanil concentrations during cardiac surgery with CPB. CLINICAL TRIAL REGISTRATION: 2017-A03153-50.

Evaluation of the Duration of Preanesthesia Consultation: Prospective and Multicenter Study.

BACKGROUND: The time allocated to the preanesthesia consultation (PAC) of a patient undergoing an elective surgical procedure is an important factor to optimize consultation sessions. The main objective of this study was to build a model predictive of the duration of the PAC. METHODS: We prospectively studied 1007 patients undergoing a PAC from January 2016 to June 2018 in 4 different hospitals. A general linear model was fitted to predict the overall duration of the PAC. Secondary models predicted the time spent on clinical evaluation and the time assigned to delivering information. RESULTS: After exclusion of 40 patients with major data inconsistencies, the mean (standard deviation [SD]) overall duration of the PAC was 11.2 (5.8) minutes, split into 6.8 (4.1) minutes of information and 4.4 (2.7) minutes of clinical evaluation. It was, respectively, 11.4 (5.9), 6.9 (4.2), and 4.4 (2.7) in the 924 patients ≥16 years of age and, respectively, 8.3 (2.3), 4.3 (1.8), and 4.1 (1.8) in 43 children. The American Society of Anesthesiologists (ASA) score, the number of comorbidities or treatment, surgery discipline, and context (ambulatory, conventional hospitalization, and intensive care unit) were significantly correlated to PAC time. In the 924 adult patients, the models had an R2 adjusted for overfitting at 0.47 for the total duration of PAC, 0.45 for the clinical examination time, and 0.24 for the information time. The estimated residual standard deviations were, respectively, 4.3, 3.1, and 2.7 minutes. CONCLUSIONS: The predictive performances of the model explaining the overall duration of PAC were average (R2 = 0.47) and should be confirmed by further studies to use it for optimizing the organization of the consultation by individualizing the time dedicated to each consultation.

Preoperative analgesic instruction and prescription reduces early home pain after outpatient surgery: a randomized controlled trial.

BACKGROUND: Home pain remains the most common complication in outpatient surgery. Optimal management requires good information and early availability of analgesics. The main objective of this randomized controlled trial was to compare the effects of pre- vs postoperative analgesic instruction and prescription on postoperative home pain. METHODS: Patients were randomized into an anesthesia consultation group (AC group) and a standard postoperative group (POP group). The AC group and the POP group received analgesic prescription and instruction during the anesthesia consultation and after surgery, respectively. The primary outcome was the incidence of home pain on postopertive day one (D1). Home pain was defined by at least one episode with a numeric rating scale score > 3/10 at rest. Treatment compliance and postoperative nausea and vomiting (PONV) were also assessed on D1 and postoperative day 7 (D7). RESULTS: One hundred and eighty-six patients were included between May 2017 and May 2018 at Rouen University Hospital, France. Ninety-four patients were randomized to the AC group and 92 to the POP group. On D1, the incidence of pain was 23/94 (24%) in the AC group and 44/92 (48%) in the POP group (P < 0.001). On D1, the rate of treatment compliance was significantly higher in the AC group than in the POP group (85% vs 69%; P = 0.02). There was no statistically significant difference in the incidence of pain or treatment compliance between groups on D7 or in PONV on D1 and on D7. CONCLUSIONS: Preoperative analgesic instruction and prescription during anesthesia consultation reduces the incidence of early postoperative home pain in outpatient surgery. TRIAL REGISTRATION: www.clinicaltrialsgov (NCT03205189); registered 2 July 2017.

RéSUMé: CONTEXTE: La douleur à la maison demeure la complication la plus fréquente après une chirurgie ambulatoire. Une prise en charge optimale nécessite de bonnes informations et la disponibilité précoce d'analgésiques. L'objectif principal de cette étude randomisée contrôlée était de comparer les effets d'instructions et d'une prescription pré- vs postopératoires d'analgésiques sur la douleur postopératoire à la maison. MéTHODE: Les patients ont été randomisés dans un groupe de consultation pré-anesthésique (groupe pré) et un groupe postopératoire standard (groupe post). Le groupe pré et le groupe post ont reçu une prescription d'analgésiques ainsi que les instructions s'y rattachant pendant la consultation en anesthésie préopératoire et après la chirurgie, respectivement. Le critère d'évaluation principal était l'incidence de douleur à la maison au premier jour postopératoire (post-op 1). La douleur à domicile était définie par un épisode de douleur ou plus avec un score > 3/10 au repos sur l'échelle d'évaluation numérique. L'observance du traitement et les nausées et vomissements postopératoires (NVPO) ont également été évalués les jours post-op 1 et 7. RéSULTATS: Cent quatre-vingt-six patients ont été inclus entre mai 2017 et mai 2018 au Centre hospitalier universitaire de Rouen. Quatre-vingt-quatorze patients ont été randomisés au groupe pré et 92 au groupe post. Au jour post-op 1, l'incidence de la douleur était de 23/94 (24 %) dans le groupe pré et de 44/92 (48 %) dans le groupe post (P < 0,001). Au jour post-op 1, le taux d'observance du traitement était significativement plus élevé dans le groupe pré que dans le groupe post (85 % vs 69 %; P = 0,02). Il n'y avait aucune différence statistiquement significative dans l'incidence de douleur ou d'observance du traitement entre les groupes au jour post-op 7 ou dans les NVPO aux jours post-op 1 et 7. CONCLUSION: L'instruction et la prescription préopératoires d'analgésiques pendant la consultation anesthésique préopératoire réduisent l'incidence de la douleur postopératoire précoce à domicile en chirurgie ambulatoire. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03205189); enregistrée le 2 juillet 2017.

Impact of Opioid-free Anesthesia After Video-assisted Thoracic Surgery: A Propensity Score Study.

BACKGROUND: Adequate postoperative morphine consumption and pain management after thoracic surgery are major issues in the prevention of respiratory complications. Opioid-free anesthesia (OFA) may decrease morphine consumption and postoperative pain. The objective of this study was to evaluate the impact of OFA on the consumption of morphine and pain after video-assisted thoracic surgery or robotic-assisted thoracic surgery. METHODS: The main objective of this retrospective study with propensity score analysis (PSA) was to compare the cumulative postoperative morphine consumption at 48 hours between an OFA group receiving dexmedetomidine, lidocaine, and ketamine; and an opioid anesthesia (OA) group receiving remifentanil plus morphine. Postoperative pain at 24 and 48 hours and respiratory and hemodynamics complications were also assessed. RESULTS: Eighty-one patients were included, 48 in the OFA group and 33 in the OA group. The cumulative postoperative morphine consumption at 48 hours was lower in the OFA group than in the OA group (28.5 mg [0 to 62.25 mg] vs 55 mg [34 to 79.5 mg], P = .002, with PSA; OFA -27.67 mg [-46 mg to -11.5 mg], P = .002). The postoperative pain score was significantly lower in the OFA group compared with the OA group at 24 hours (2 [0 to 4] vs 3 [2 to 5], P = .064, with PSA; OFA -1.40 [-2.47 to -0.33], P = .0088) and 48 hours (0 [0 to 3] vs 2.5 [0 to 5], P = .034, with PSA; OFA -1.87 [-3.45 to -0.28], P = .021). There were no differences between groups concerning respiratory or hemodynamic complications. CONCLUSIONS: Our results suggest that OFA after video-assisted thoracic surgery or robotic-assisted thoracic surgery is safe and is associated with less postoperative morphine cumulative consumption and pain at 48 hours.

Anesthetic Management for Awake Tubeless Suspension Microlaryngoscopy.

OBJECTIVES/HYPOTHESIS: Patients' eligibility for bilateral selective laryngeal reinnervation surgery is evaluated by suspension microlaryngoscopy (SML) examination with laryngeal electromyography (LEMG). Maintaining spontaneous ventilation, with remifentanil sedation/analgesia without endotracheal tube, to allow the patient to phonate with the surgeon during awake, LEMG is a major challenge for the anesthesiologist and the otorhinololaryngologist. The objective of this study was to evaluate the safety and efficacy of a novel anesthesia protocol to manage airway access during awake tubeless SML. STUDY DESIGN: Retrospective study. METHODS: Anesthesia records of patients undergoing awake SML with LEMG were retrospectively analyzed. Procedures were performed with remifentanil sedation/analgesia with targeted controlled infusion (TCI) in combination with local anesthesia. The main outcome was the failure rate of the anesthesia protocol during the procedure. Secondary outcomes were as follows: rate of apnea requiring ventilation, airway bleeding, regurgitation, hemodynamic data as well as vasopressor use, complications, and surgeon satisfaction with the procedure. RESULTS: Data were obtained for 39 patients between November 2017 and September 2019, the mean age was 52 years and 29 (74%) were female. All procedures were completed without complications (0% [0-9]). Three patients (8% [1.6-20.8]) had an intraoperative episode of hypoxemia requiring mask reventilation. There was no airway bleeding, no regurgitation, and no hypotensive episode. Three patients (8% [1.6-20.8]) had noninvasive ventilation for respiratory distress after the end of the procedure. CONCLUSIONS: Our results show that awake tubeless SML allowing phonation during LEMG can be realized under sedation and local anesthesia. However, further data are needed concerning the intraoperative and postoperative safety of the procedure. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2669-E2675, 2021.