Oral fluid intake during the first stage of labour: A randomised trial.

BACKGROUND: Obstetric anaesthesia has been associated with concern for the inhalation of gastric contents for many years, justifying fasting during labour. However, many anaesthesiologists and obstetricians now allow fluid intake during labour. OBJECTIVE(S): We hypothesised that allowing oral fluid intake during labour is not associated with increased gastric contents. We used ultrasound assessment of gastric contents to evaluate this hypothesis. DESIGN: A randomised, single-blind and intention-to-treat noninferiority trial comparing antral area measured by ultrasound in fasting parturients and in those who were allowed to drink fluid for 90 min after randomisation. SETTING: Tenon University Hospital, Assistance Publique Hôpitaux de Paris, Paris, France. PATIENTS: Pregnant women, aged from 18 to 40 years and from week 36 of an uncomplicated singleton gestation, were randomised into a fasting group and a fluid intake group after admission to the delivery room. Of the 184 patients screened, data from 125 were analysed: fasting group (62), fluid intake group (63). INTERVENTION: Women in the fluid intake group were allowed to drink up to 400 ml of apple juice for 90 min after randomisation. MAIN OUTCOME MEASURE: We compared the percentage of women with an 'empty stomach' between the two groups: empty stomach was defined as an antral cross-sectional area (CSA) less than 300 mm assessed in a semirecumbent position with a 45-degree head-up tilt. RESULTS: At full cervical dilatation an antral CSA less than 300 mm was measured in 76 and 79% of the parturients in the fasting group and the fluid intake groups respectively (P = 0.633). CONCLUSION: The current study reveals that the percentage of pregnant women with an 'empty stomach', defined by an antral CSA less than 300 mm in a semirecumbent position with a 45-degree head-up tilt, was comparable at full cervical dilation among those who remained nil by mouth and those allowed to drink up to 400 ml for 90 min after their randomisation. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT02362815.

Is there a place for regional anesthesia in nonoperating room anesthesia?

PURPOSE OF REVIEW: General anesthesia and monitored anesthesia care (MAC) are the most widely used techniques in nonoperating room anesthesia (NORA). However, regional anesthesia is slowly finding viable applications in this field. This review aims at providing an update on the current practice of regional anesthesia techniques outside of the operating theatre. RECENT FINDINGS: Some anesthetic departments have implemented the use of regional anesthesia in novel applications outside of the operating room. In most cases, it remains an adjunct to general anesthesia but is sometimes used as the sole anesthetic technique. The use of the paravertebral block during radiofrequency ablation of different tumors is a recent application in interventional radiology. In emergency medicine, regional anesthesia is gaining traction in analgesia for trauma patients. SUMMARY: Regional anesthesia is finding its way into broader applications every day, offering a range of potential benefits in anesthetic care. Its implementation in NORA is promising and may aid in decreasing patient morbidity. However, great care should be taken in applying the recommended safety precautions for regional anesthesia in any setting.

Comparison of several methods for pain management after video-assisted thoracic surgery for pneumothorax: an observational study.

BACKGROUND: There is no defined gold standard for pain management after video-assisted thoracic surgery (VATS) for pneumothorax. In addition to systemic analgesia, various loco-regional analgesic techniques have been proposed but remain poorly evaluated in this context. We aimed to assess the analgesic efficacy of several of these techniques for the management of postoperative pain. METHODS: We conducted a monocentric prospective observational cohort study from February 2017 to April 2018 in patients suffering from spontaneous pneumothorax and scheduled for VATS (n = 59). Patients received systemic analgesia (i) alone (n = 15); (ii) combined with a continuous paravertebral block (n = 9); (iii) combined with a continuous serratus plane block (n = 19); or (iv) single-shot serratus plane block (n = 16) as decided by the attending physician. Pain scores and analgesic-related side effects were prospectively collected by an independent observer during the first postoperative 72 h. The primary endpoint criterion was the cumulative oral morphine consumption at the end of the third postoperative day. Statistical analysis used univariate and multivariate step-by-step forward logistic regression models to determine risk factors associated with the main criteria. RESULTS: Mean pain scores and morphine consumption were not significantly different between the 4 groups. In the multivariate analysis, the use of a continuous serratus plane block through a catheter was the only technique associated with a reduced incidence of high-dose oral morphine consumption (OR 0.09-95%CI [0.01-0.79], p = 0.03). CONCLUSION: This study suggests that serratus plane block combined with continuous infusion through a catheter may have some benefits, although further studies are needed to confirm these results and determine the true place of the serratus plane block in pain management after VATS for pneumothorax.

Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: A double-blind randomised controlled trial.

BACKGROUND: Thoracic surgery for lung resection is associated with a high incidence of postoperative pulmonary complications. Controlled ventilation with a large tidal volume has been documented to be a risk factor for postoperative respiratory complications after major abdominal surgery, whereas the use of low tidal volumes and positive end-expiratory pressure (PEEP) has a protective effect. OBJECTIVE: To evaluate the effects of ventilation with low tidal volume and PEEP on major complications after thoracic surgery. DESIGN: A double-blind, randomised controlled study. SETTING: A multicentre trial from December 2008 to October 2011. PATIENTS: A total of 346 patients undergoing lobectomy or pneumonectomy for lung cancer. MAIN OUTCOME MEASURES: The primary outcome was the occurrence of major postoperative complications (pneumonia, acute lung injury, acute respiratory distress syndrome, pulmonary embolism, shock, myocardial infarction or death) within 30 days after surgery. INTERVENTIONS: Patients were randomly assigned to receive either lung-protective ventilation (LPV group) [tidal volume 5 ml kg ideal body weight + PEEP between 5 and 8 cmH2O] or nonprotective ventilation (control group) (tidal volume 10 ml kg ideal body weight without PEEP) during anaesthesia. RESULTS: The trial was stopped prematurely because of an insufficient inclusion rate. Major postoperative complications occurred in 23/172 patients in the LPV group (13.4%) vs. 38/171 (22.2%) in the control group (odds ratio 0.54, 95% confidence interval, 0.31 to 0.95, P = 0.03). The incidence of other complications (supraventricular cardiac arrhythmia, bronchial obstruction, pulmonary atelectasis, hypercapnia, bronchial fistula and persistent air leak) was also lower in the LPV group (37.2 vs. 49.4%, odds ratio 0.60, 95% confidence interval, 0.39 to 0.92, P = 0.02).The duration of hospital stay was shorter in the LPV group, 11 [interquartile range, 9 to 15] days vs. 12 [9 to 16] days, P = 0.048. CONCLUSION: Compared with high tidal volume and no PEEP, LPV combining low tidal volume and PEEP during anaesthesia for lung cancer surgery seems to improve postoperative outcomes. TRIALS REGISTRATION: ClinicalTrials.gov number: NCT00805077.

Evaluation of early antimicrobial therapy adaptation guided by the BetaLACTA® test: a case-control study.

BACKGROUND: Rapid diagnostic tests detecting microbial resistance are needed for limiting the duration of inappropriateness of empirical antimicrobial therapy (EAT) in intensive care unit patients, besides reducing the use of broad-spectrum antibiotics. We hypothesized that the betaLACTA® test (BLT) could lead to early increase in the adequacy of antimicrobial therapy. METHODS: This was a case-control study. Sixty-one patients with BLT-guided adaptation of EAT were prospectively included, and then matched with 61 "controls" having similar infection characteristics (community or hospital-acquired, and source of infection), in whom EAT was conventionally adapted to antibiogram results. Endpoints were to compare the proportion of appropriate (primary endpoint) and optimal (secondary endpoint) antimicrobial therapies with each of the two strategies, once microbiological sample culture results were available. RESULTS: Characteristics of patients, infections and EAT at inclusion were similar between groups. Nine early escalations of EAT occurred in the BLT-guided adaptation group, reaching 98% appropriateness vs. 77% in the conventional adaptation group (p < 0.01). The BLT reduced the time until escalation of an inappropriate EAT from 50.5 (48-73) to 27 (24-28) hours (p < 0.01). Seventeen early de-escalations occurred in the BLT-guided adaptation group, compared to one in the conventional adaptation group, reducing patients' exposure to broad-spectrum beta-lactam such as carbapenems. In multivariate analysis, use of the BLT was strongly associated with early appropriate (OR = 18 (3.4-333.8), p = 0.006) and optimal (OR = 35.5 (9.6-231.9), p < 0.001) antimicrobial therapies. Safety parameters were similar between groups. CONCLUSIONS: Our study suggests that a BLT-guided adaptation strategy may allow early beta-lactam adaptation from the first 24 hours following the beginning of sepsis management.

Modelling of the optimal bupivacaine dose for spinal anaesthesia in ambulatory surgery based on data from systematic review.

BACKGROUND: Spinal bupivacaine is used for day-case surgery but the appropriate dose that guarantees hospital discharge is unknown. OBJECTIVE: We sought to determine the spinal bupivacaine dose that prevents delayed hospital discharge in ambulatory surgery. DESIGN: Systematic review of clinical trials. DATA SOURCES: Comprehensive search in electronic databases of studies published between 1996 and 2014 reporting the use of spinal bupivacaine in ambulatory patients. Additional articles were retrieved through hyperlinks and by manually searching reference lists in original articles, review articles and correspondence published in English and French. MAIN OUTCOME MEASURES: Data were used to calculate, motor block duration and discharge time, an estimated maximal effect (Emax: maximum theoretical time of motor block) and the effective dose to obtain half of Emax (D50) with 95% confidence intervals (CIs). A simulation was performed to determine the dose corresponding to a time to recovery of 300 min for motor function, and 360 min for discharge, in 95% of the patients. RESULTS: In total, 23 studies (1062 patients) were included for analysis of the time to recovery of motor function, and 12 studies (618 patients) for the time to hospital discharge. The Emax for recovery of motor function was 268 min [95% CI (189 to 433 min)] and the D50 was 3.9 mg [95% CI (2.3 to 6.2 mg)]. A 7.5-mg dose of bupivacaine enables resolution of motor block and ambulation within 300 min in 95% of the patients. A 5-mg dose or less was associated with an unacceptable failure rate. CONCLUSION: Ambulatory surgery is possible under spinal anaesthesia with bupivacaine although the dose range that ensures reliable anaesthesia with duration short enough to guarantee ambulatory management is narrow.

Optimal pain management for radical prostatectomy surgery: what is the evidence?

BACKGROUND: Increase in the diagnosis of prostate cancer has increased the incidence of radical prostatectomy. However, the literature assessing pain therapy for this procedure has not been systematically evaluated. Thus, optimal pain therapy for patients undergoing radical prostatectomy remains controversial. METHODS: Medline, Embase, and Cochrane Central Register of Controlled Trials were searched for studies assessing the effects of analgesic and anesthetic interventions on pain after radical prostatectomy. All searches were conducted in October 2012 and updated in June 2015. RESULTS: Most treatments studied improved pain relief and/or reduced opioid requirements. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis and consensus recommendations. CONCLUSIONS: This systematic review reveals that there is a lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies assessed unimodal analgesic approaches rather than a multimodal technique. There is a need for more procedure-specific studies comparing pain and analgesic requirements for open and minimally invasive surgical procedures. Finally, while we wait for appropriate procedure specific evidence from publication of adequate studies assessing optimal pain management after radical prostatectomy, we propose a basic analgesic guideline.

Combination of dexamethasone and local anaesthetic solution in peripheral nerve blocks: A meta-analysis of randomised controlled trials.

BACKGROUND: Dexamethasone decreases postoperative pain and prolongs the duration of local anaesthetic peripheral nerve blocks in studies including a limited number of patients. OBJECTIVE: The objective of this study is to evaluate the effect of combining dexamethasone with local anaesthetic on sensory and motor peripheral nerve blockade in adults. DESIGN: A systematic review with meta-analysis of randomised controlled trials. DATA SOURCES: We systematically searched in Medline, Embase, Google Scholar and Cochrane Controlled Trials Register up to December 2013. ELIGIBILITY CRITERIA: Randomised trials testing dexamethasone combined with local anaesthetic. RESULTS: Twelve trials (1054 patients, 512 receiving perineural dexamethasone) were included. Ten studies evaluated dexamethasone for brachial plexus nerve block. Four to 10 mg dexamethasone-containing local anaesthetic solutions had a faster onset of action and resulted in a significant increase in the duration of analgesia [weighted mean difference (WMD) 351 min, 95% confidence interval (95% CI) 288 to 413, P < 0.001] and motor blockade (WMD 277 min, 95% CI 167 to 387, P < 0.001) compared with local anaesthetic solutions alone. Time to onset of sensory and motor blocks was significantly reduced with dexamethasone (WMD -78 s, 95% CI -112 to -44, and -90 s, 95% CI -131 to -48, respectively). Dexamethasone significantly decreased postoperative nausea and vomiting (PONV, 9 vs. 27%, relative risk 0.36, 95% CI 0.19 to 0.70). Subgroup analyses showed that dexamethasone approximately doubled the duration of postoperative analgesia when it was combined with intermediate-acting (lidocaine, mepivacaine) or long-acting (bupivacaine, ropivacaine) local anaesthetics. CONCLUSION: Combining dexamethasone with local anaesthetics results in a prolongation of the duration of peripheral nerve block.

Dexmedetomidine reduces propofol and remifentanil requirements during bispectral index-guided closed-loop anesthesia: a double-blind, placebo-controlled trial.

BACKGROUND: The α2-adrenergic agonist dexmedetomidine is a sedative and can be used as an adjunct to anesthetics. Our primary goal was thus to determine the extent to which dexmedetomidine reduces the requirement for propofol and remifentanil. METHODS: This double-blinded, randomized study (NCT00921284) used an automated dual closed-loop administration to maintain the Bispectral Index between 40 and 60. Sixty-6 ASA physical status I and II patients were given either dexmedetomidine (1 µg/kg over 10 minutes followed by a continuous infusion of 0.5 µg/kg/h throughout surgery) or comparable volumes of saline as a placebo. Propofol and remifentanil requirements were compared using nonparametric tests and expressed as medians (interquartile ranges). RESULTS: Twenty-eight patients in each group completed the study. Patients given dexmedetomidine required less propofol (1.0 [0.7-1.3] vs 1.3 [1.0-1.7] mg/kg, P = 0.002) and remifentanil (1.2 [1.0-1.4] vs 1.6 [1.1-2.8] µg/kg, P = 0.02) for anesthetic induction. The propofol dosage required for anesthetic maintenance was 29% (with a 95% confidence interval, 18-40) lower in patients given dexmedetomidine (2.2 [1.5-3.0] vs 3.1 [2.4-4.5] mg/kg/h, P = 0.005), whereas the remifentanil dosage was not significantly different (0.16 [0.09-0.17] vs 0.14 [0.13-0.21] µg/kg/h with P = 0.3). The incidence of adverse events, including hemodynamic instability and delayed recovery, was comparable with and without dexmedetomidine. The first postoperative request for morphine analgesia was delayed in patients given dexmedetomidine (median fourth hour vs first hour, P = 0.008). CONCLUSIONS: Dexmedetomidine administration significantly reduced the requirement for both propofol and remifentanil during anesthetic induction and reduced propofol use during maintenance of anesthesia. Dexmedetomidine also delayed postoperative analgesic use. Dexmedetomidine is a useful adjuvant that reduces anesthetic requirement and provides postoperative analgesia.

Management of anesthetic emergencies and complications outside the operating room.

PURPOSE OF REVIEW: Anesthesia outside the operating room is commonly uncomfortable and risky. In this setting, anesthetic emergencies or complications may occur. This review aims to report the most recent updates regarding the management of prehospital anesthesia, anesthesia in the trauma and emergency rooms, and anesthesia for endoscopy and interventional radiology. RECENT FINDINGS: After tracheal intubation failure, airway control of outpatients could be achieved by pharmacologically assisted laryngeal mask insertion. Management of traumatic injured patients is best guided in the frame of checklists. Monitoring sedation in this setting is challenging notably because of the threat of haemodynamic instability. Unfortunately, BIS monitoring cannot be recommended to guide sedation in this setting. Ketamine can be used to prevent hypotension during prehospital anesthesia or procedural sedation, especially as its neuroprotective effects have been recently best understood. Target-controlled infusion propofol administration with small concentration increments is adapted to prevent hypotension and hypoxaemia during sedation for gastrointestinal endoscopy and interventional radiology. Target-controlled infusion remifentanil administration is also adapted to many procedures. SUMMARY: Anesthesia outside the operating room requires careful monitoring to avoid side-effects and education of nonanaesthetists when they are involved. A useful tool is to continuously improve the protocols and checklists to make anesthesia in this setting safer.

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.

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.

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.

Risk factors for prolonged time to hospital discharge after ambulatory cholecystectomy under general anaesthesia. A retrospective cohort study.

BACKGROUND: Although predictive models have already integrated demographic factors and comorbidities as risk factors for a prolonged hospital stay, factors related to anaesthesia management in ambulatory surgery have not been yet characterized. This study aims to identify anaesthetic factors associated with a prolonged discharge time in ambulatory surgery. METHODS: All clinical records of patients who underwent ambulatory cholecystectomy in a French University Hospital (Hôpital Saint Antoine, Paris) between January 1st, 2012 and December 31st, 2018 were retrospectively reviewed. The primary endpoint was the discharge time, defined as the time between the end of surgery and discharge. A multivariable Cox proportional-hazards model was fitted to investigate the factors associated with a prolonged discharge time. RESULTS: Five hundred and thirty-five (535) patients were included. The median time for discharge was 150 min (interquartile range - IQR [129-192]). A bivariable analysis highlighted a positive correlation between discharge timeline and the doses-weight of ketamine and sufentanil. In the multivariable Cox proportional hazards model analysis, the anaesthesia-related factors independently associated with prolonged discharge time were the dose-weight of ketamine in interaction with the dose weight of sufentanil (HR 0.10 per increment of 0.1 mg/kg of ketamine or 0.2 µg/kg of sufentanil, CI 95% [0.01-0.61], p = 0.013) and the non-use of a non-steroidal anti-inflammatory drug (NSAID) (HR 0.81 [0.67-0.98], p = 0.034). Twenty patients (4%) had unscheduled hospitalization following surgery. CONCLUSION: Anaesthesia management, namely the use of ketamine and the non-use of NSAID, affects time to hospital discharge.

A double blind randomized trial of wound infiltration with ropivacaine after breast cancer surgery with axillary nodes dissection.

BACKGROUND: The effect of local infiltration after breast surgery is controversial. This prospective double blind randomized study sought to document the analgesic effect of local anaesthetic infiltration after breast cancer surgery. METHODS: Patients scheduled for mastectomy or tumorectomy and axillary nodes dissection had immediate postoperative infiltration of the surgical wound with 20 ml of ropivacaine 7.5 mg.ml-1 or isotonic saline. Pain was assessed on a visual analogue scale at H2, H4, H6, H12, H24, H72, and at 2 month, at rest and on mobilization of the arm. Patient'comfort was evaluated with numerical 0-3 scales for fatigue, quality of sleep, state of mood, social function and activity. RESULTS: Twenty-two and 24 patients were included in the ropivacaine and saline groups respectively. Postoperative pain was lower at rest and on mobilization at 2, 4 and 6 hour after surgery in the ropivacaine group. No other difference in pain intensity and patient 'comfort scoring was documented during the first 3 postoperative days. Patients did not differ at 2 month for pain and comfort scores. CONCLUSION: Single shot infiltration with ropivacaine transiently improves postoperative pain control after breast cancer surgery. TRIAL REGISTRATION NUMBER: NCT01404377.