Cost-effectiveness analysis comparing epidural, patient-controlled intravenous morphine, and continuous wound infiltration for postoperative pain management after open abdominal surgery.

BACKGROUND: Continuous wound infiltration (CWI), i.v. patient-controlled analgesia (i.v.-PCA), and epidural analgesia (EDA) are analgesic techniques commonly used for pain relief after open abdominal surgery. The aim of this study was to evaluate the cost-effectiveness of these techniques. METHODS: A decision analytic model was developed, including values retrieved from clinical trials and from an observational prospective cohort of 85 patients. Efficacy criteria were based on pain at rest (VAS ≤ 30/100 mm at 24 h). Resource use and costs were evaluated from medical record measurements and published data. Probabilistic sensitivity analysis (PSA) was performed. RESULTS: When taking into account all resources consumed, the CWI arm (€ 6460) is economically dominant when compared with i.v.-PCA (€ 7273) and EDA (€ 7500). The proportion of patients successfully controlled for their postoperative pain management are 77.4%, 53.9%, and 72.9% for CWI, i.v.-PCA, and EDA, respectively, demonstrating the CWI procedure to be both economically and clinically dominant. PSA reported that CWI remains cost saving in 70.4% of cases in comparison with EDA and in 59.2% of cases when compared with PCA. CONCLUSIONS: Device-related costs of using CWI for pain management after abdominal laparotomy are partly counterbalanced by a reduction in resource consumption. The cost-effectiveness analysis suggests that CWI is the dominant treatment strategy for managing postoperative pain (i.e. more effective and less costly) in comparison with i.v.-PCA. When compared with EDA, CWI is less costly with almost equivalent efficacy. This economic evaluation may be useful for clinicians to design algorithms for pain management after major abdominal surgery.

Benzodiazepines and hip fractures in elderly people: case-control study.

OBJECTIVE: To determine whether benzodiazepines are associated with an increased risk of hip fracture. DESIGN: Case-control study. PARTICIPANTS: All incident cases of hip fracture not related to traffic accidents or cancer in patients over 65 years of age. 245 cases were matched to 817 controls. SETTING: Emergency department of a university hospital. MAIN OUTCOME MEASURES: Exposure to benzodiazepines and other potential risk or protective factors or lifestyle items. RESULTS: The use of benzodiazepines as determined from questionnaires, medical records, or plasma samples at admission to hospital was not associated with an increased risk of hip fracture (odds ratio 0.9, 95% confidence interval 0.5 to 1.5). Hip fracture was, however, associated with the use of two or more benzodiazepines, as determined from questionnaires or medical records but not from plasma samples. Of the individual drugs, only lorazepam was significantly associated with an increased risk of hip fracture (1.8, 1.1 to 3.1). CONCLUSION: Except for lorazepam, the presence of benzodiazepines in plasma was not associated with an increased risk of hip fracture. The method used to ascertain exposure could influence the results of case-control studies.

[Prehabilitation. Preparing patients for surgery to improve functional recovery and reduce postoperative morbidity]. / La préhabilitation. Préparer les patients à la chirurgie pour améliorer la récupération fonctionnelle et réduire la morbidité postopératoire.

OBJECTIVE: Prehabilitation consists in providing a repetitive physical exercise before surgery to improve the postoperative recovery course. This review aims to evaluate the feasibility and the expected benefits of prehabilitation on the postoperative recovery course and the reduction of the postoperative morbidity. DATA SOURCES: Data research has focused on English-language articles in the Medline database, published from 1989 to 2013. Keywords, used separately or in combination, were: prehabilitation, functional capacity, postoperative morbidity, physical activity. STUDY SELECTION: Selected articles were original articles, clinical cases, review articles and meta-analysis. DATA EXTRACTION: Articles were analyzed for feasibility, benefits and limitations of preoperative physical preparation techniques. DATA SYNTHESIS: Poor preoperative functional status is associated with increased postoperative morbidity. Elderly are more prone to postoperative complications. The improvement of preoperative physical status of these patients is possible and may reduce morbidity and allow faster recovery after major surgery. In order to improve efficiency, the training program must provide endurance and muscle reinforcement exercises, whose intensity must be adapted to the patient's baseline physical abilities. An average of three sessions per week over a period of six to eight weeks before surgery seemed a good compromise between feasibility and effectiveness. CONCLUSION: The effectiveness of prehabilitation has been demonstrated in cardiovascular surgery and probably in abdominal surgery. Prehabilitation must be integrated into the overall patient medical management, and must be associated with preoperative refeeding and postoperative rehabilitation protocols. By optimizing all stages of the surgical patient management, from diagnosis to recovery, prognosis of high-risk surgical patients could be improved.

Influence of pain on postoperative ventilatory disturbances. Management and expected benefits.

Abdominal surgery induces postoperative ventilatory dysfunction related to a combination of reflex diaphragmatic inhibition, respiratory muscle injury and pain. The role of pain is difficult to isolate from other components. Thoracic epidural analgesia using local anesthetics is able to partially reverse the diaphragmatic dysfunction. However, this effect seems not directly related to analgesia. Regardless of the mechanisms, epidural analgesia has been shown to improve the postoperative ventilation and to prevent the occurrence of pulmonary complications. Pain relief, either by parenteral administration of opiate, and/or parietal blockade has been shown to improve the diaphragm motion and the overall respiratory status. All analgesic strategies may facilitate the implementation of postoperative physiotherapy which has a significant interest in preventing postoperative pulmonary complications.

[Perioperative management of patients with systemic scleroderma]. / Prise en charge périopératoire du patient sclérodermique.

Systemic sclerosis (SSc) is an auto-immune disease characterized by vasculopathy and the combination of microangiopathy and tissue collagen deposit leading to skin, digestive, pulmonary, myocardial and renal injuries. These repercussions could be challenging for anesthesiologists and associated with difficulties in airway management, and occurrence of congestive right heart failure or acute kidney crisis. The aim of this review is to review the physiopathology and the progression of the SSc, as well as to provide a strategy of perioperative management of these patients.

[Cost analysis comparing single-use (Ambu® aScope™) and conventional reusable fiberoptic flexible scopes for difficult tracheal intubation]. / Analyse de coût comparant les fibroscopes à usage unique (Ambu®aScope™) et les fibroscopes réutilisables pour l'intubation difficile.

OBJECTIVE: Recommendations on difficult tracheal intubation constrain each surgical block to have a fiberscope available. Reusable fiberscope presents the problem of availability, the risk of non-conventional infections transmission and the cost. Single-use fiberscopes are presently available (Ambu® aScope™). This medico-economic study aims to assess the cost of using a reusable fiberscope as compared to the single use fiberscope. STUDY DESIGN: Cost minimization analysis. MATERIAL: Reusable fiberscope Pentax® FB 15P (Pentax France, Argenteuil) and single-use fiberscope Ambu® aScope™ (Ambu A/S, Ballerup, Denmark). METHOD: Minimization-cost analysis conducted between 2006 and 2012. The amortization cost per utilization for two reusable fiberscopes took into account the acquisition and maintenance costs, as well as the costs related to disinfection. The cost of the single use fiberscope was calculated according to its acquisition cost. RESULTS: The total cost of the reusable material was 55,874€ over 6years, corresponding to a unitary cost of 206€ per fiberscopy. During this period, 780 sterilizations were carried out for a total cost of 32,611€. Acquisition and maintenance costs were respectively 18,382€ and 4880€. The cost of the single use fiberscope is of 200€ per fiberscopy. CONCLUSION: This medico-economic evaluation shows that the utilization cost of single use and reusable fiberscopes are very close. This should be analyzed at the light of some benefits of using single use devices for the difficult tracheal intubation.

[Neurological complications of the regional anesthesia: analysis of the expertises and conclusions of the Regional Commissions for Conciliation and Compensation]. / Complications neurologiques de l'anesthésie locorégionale : analyse des expertises et conclusions des CRCI.

All the files of complications of regional anaesthesias requiring an expertise for a Regional Commission for Conciliation and Compensation for medical accidents (CRCI) between 2003 and 2008 were analyzed. The objective was to estimate the homogeneity of the appointed experts, their opinions and the opinions of the CRCI. Querying the database, shared by the National Office for Compensation for Medical Accidents (ONIAM) and the CRCI, and identified 40 files corresponding to the selection criteria. The expertise carried out involved an anaesthetist in 27 cases, always registered, either on the national list of the experts in medical accidents, or on one list of court-appointed experts. Conversely, in 13 cases, no specialist performing himself the technique in question was involved in the expertise, and sometimes the expert was registered on any list. Mostly, the non-specialists do not conclude to medical malpractice. This was not the case in a single file, where the anaesthetist sought and obtained the addition of an anaesthetist in a new expertise, which concluded differently. Damages assessed were highly variable, but the given evidence provided to understand why. The CRCI have generally followed the opinions of the experts, except in a few cases where the evidence allowed a different opinion without requiring a new expertise. In conclusion, the abnormalities in the appointment of experts do not seem to have had consequences in terms of damage assessment, but may alter the balance between causes faulty and not faulty, in favour of the latter.

[Ultrasound control of local anaesthetic location after TAP block performed using landmark-based technique: a cohort study]. / Contrôle échographique du site d'injection lors de la réalisation d'un TAP bloc à l'aveugle : une étude ouverte de cohorte.

OBJECTIVE: TAP is a regional anaesthetic technique where local anaesthesic (LA) is injected between the internal oblique and the transversus abdominis muscles in order to block intercostal nerves. The technique originally described, is based on the identification of the lumbar triangle of Petit as the area where to insert the needle before the LA injection. We performed a study to determine, using ultrasonography, the actual location of the LA when TAP block was performed using landmark-based technique. STUDY DESIGN: Prospective and observational study. METHODS: Fifty-two patients scheduled for ileostomy closure surgery under general anaesthesia received a TAP block (20 mL 0.75% ropivacaine) based on standard anatomical landmarks technique. Ultrasonography was used immediately after the block to determine the LA placement. Failed blocks were considered when the patient required intravenous morphine in the immediate postoperative period for pain localised at the operative site. RESULTS: LA solution was injected in the right place in 14 cases out of 52. Only one of these patient received morphine in the postoperative period. In the remaining 38 blocks, the LA was administered in adjacent anatomical structures and 25 failed. Two injections in the peritoneum were observed. CONCLUSION: The localization of LA after the TAP block being performed by landmark-based techniques is highly variable. In the majority of patients, the LA was injected in adjacent anatomical structures with unpredictable block results. This may promote the use of ultrasound-guided technique to perform the TAP block.