An observer tool to enhance learning of medical students during simulation training of cardiopulmonary resuscitation: a randomised controlled trial.

BACKGROUND: Simulation training in cardiopulmonary resuscitation (CPR) is effective but active practice time is limited given the large number of students and the learning effect size remains small. To improve learning during observation, the use of an observer tool (OT) has been advocated. The aim was to assess the value of OT to improve medical students' learning outcomes during CPR simulation training. METHODS: This prospective, randomized study took place during CPR training of medical students. The workshop targeted recognition of unconsciousness, absence of breathing, call for help, cardiac massage and defibrillation. Students practicing in dyads were randomized to use an OT (i.e., a checklist summarizing CPR skills and step-by-step actions) (OT +) or not (OT-) when observing others. At the end of the training, the global performance of the dyad was assessed by an evaluator using the OT checklist (primary outcome). The non-technical skills (NTS), chest compression quality, perceived improvement in knowledge and skills and knowledge score (MCQ) were also recorded. RESULTS: The student dyads were included (OT + : n = 40 and OT-: n = 41). Immediately after training, the global performance was similar between the two groups: OT + : 24 [23-25] and OT-: 23 [21-24] (out of 25), p = 0.052. However, better learning of breathing assessment and cardiac massage performance, as well as a better knowledge score, were found in the OT + group. No significant difference was observed for NTS or perceived improvement in knowledge and skills. Satisfaction was higher in the OT- group. CONCLUSIONS: The use of an OT during CPR simulation did not show any pedagogical benefit on the global performance of medical students. However, a potential benefit was found for several important secondary outcomes. Further studies are needed to confirm these positive results.

Assessing the Clinical, Economic, and Health Resource Utilization Impacts of Prefilled Syringes Versus Conventional Medication Administration Methods: Results From a Systematic Literature Review.

OBJECTIVE: The objective of this systematic review was to assess the clinical, economic, and health resource utilization outcomes associated with the use of prefilled syringes in medication administration compared with traditional preparation methods. DATA SOURCES: We conducted a systematic literature review to evaluate outcomes such as medication errors, wastage, time savings, and contamination in prefilled syringes. Our search encompassed multiple databases, including PubMed and Embase, for studies published between January 1, 2017, and November 1, 2022. STUDY SELECTION AND DATA EXTRACTION: Peer-reviewed publications meeting our inclusion criteria underwent rigorous screening, including title, abstract, and full-text article assessments, performed by two reviewers. DATA SYNTHESIS: Among reviewed articles, 24 met our eligibility criteria. Selected studies were primarily observational (46%) and conducted in Europe (46%). Our findings indicated that prefilled syringes consistently reduced medication errors (by 10%-73%), adverse events (from 1.1 to 0.275 per 100 administrations), wastage (by up to 80% of drug), and preparation time (from 4.0 to 338.0 seconds) (ranges varied by drug type, setting, and dosage). However, there was limited data on contamination. Economically, prefilled syringes reduced waste and error rates, which may translate into overall savings. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: This review highlights the value of prefilled syringes, which can streamline medication delivery, save nursing time, and reduce preventable medication errors. Moreover, prefilled syringes have the potential to minimize medication wastage, optimizing resource utilization and efficiency in health care settings. CONCLUSION AND RELEVANCE: Our findings provide new insights into clinical and economic benefits of prefilled syringe adoption. These benefits include improved medication delivery and safety, which can lead to time and cost reductions for health care departments, hospitals, and health systems. However, further real-world research on clinical and economic outcomes, especially in contamination, is needed to better understand the benefits of prefilled syringes.

Postoperative nausea and vomiting: is the big little problem becoming a smaller little problem?

Postoperative nausea and vomiting (PONV) has been identified as a big (very frequently encountered) little (not linked to life-threatening outcomes) problem. Traditional drugs (dexamethasone, droperidol or similar drugs, serotonin receptor antagonists) each have significant but limited effect, leading to an increasing use of combination therapies. High-risk patients, often identified through use of risk scoring systems, remain with a significant residual risk despite combining up to three traditional drugs. A recent correspondence in this Journal proposes the use of up to five anti-emetic drugs to further minimise the risk. This disruptive strategy was supported by favourable initial results, absence of side-effects and lower acquisition costs of the added new drugs (aprepitant and palonosetron) because of their recent loss of patent protection. These results are provocative and hypothesis generating, but need confirmation and do not warrant immediate changes in clinical practice. The next steps will also necessitate wider implementation of protocols protecting patients from PONV and a search for additional drugs and techniques aimed at treating established PONV.

Strategy to Develop a Common Simulation Training Program: Illustration with Anesthesia and Intensive Care Residency in France.

Phenomenon: The urgency of having fair and trustworthy competency-based assessment in medical training is growing. Simulation is increasingly recognized as a potent method for building and assessing applied competencies. The growing use of simulation and its application in summative assessment calls for comprehensive and rigorously designed programs. Defining the current baseline of what is available and feasible is a crucial first step. This paper uses anesthesia and intensive care (AIC) in France as a case study in how to document this baseline. Approach: An IRB-approved, online anonymous closed survey was submitted to AIC residency program directors and AIC simulation program directors in France from January to February 2021. The researcher-developed survey consisted of 65 questions across five sections: centers' characteristics, curricular characteristics, courses' characteristics, instructors' characteristics, and simulation perceptions and perspectives. Findings: The participation rate was 31/31 (100%) with 29 centers affiliated with a university hospital. All centers had AIC simulation activities. Resident training was structured in 94% of centers. Simulation uses were training (100%), research and development (61%), procedural or organizational testing (42%), and summative assessment (13%). Interprofessional full-scale simulation training existed in 90% of centers. Procedural training on simulators prior to clinical patients' care was performed "always" in 16%, "most often" in 45%, "sometimes" in 29% and "rarely" or "not" in 10% of centers. Simulated patients were used in 61% of centers. Main themes were identified for procedural skills, full-scale and simulated patient simulation training. Simulation activity was perceived as increasing in 68% of centers. Centers expressed a desire to participate in developing and using a national common AIC simulation program. Insights: Based on our findings in AIC, we demonstrated a baseline description of nationwide simulation activities. We now have a clearer perspective on a decentralized approach in which individual institutions or regional consortia conduct simulation for a discipline in a relatively homogeneous way, suggesting the feasibility for national guidelines. This approach provides useful clues for AIC and other disciplines to develop a comprehensive and meaningful program matching existing expectations and closing the identified gaps.

An observer tool to enhance learning of incoming anesthesia residents' skills during simulation training of central venous catheter insertion: a randomized controlled trial.

BACKGROUND: Central venous catheter (CVC) insertion using simulation is an essential skill for anesthesiologists. Simulation training is an effective mean to master this skill. Given the large number of residents and the limited duration of training sessions, the active practice time is limited and residents remain observers of their colleagues for much of the session. To improve learning during observation periods, the use of an observer tool (OT) has been advocated but its educational effectiveness is not well defined. METHODS: Incoming anesthesia residents were randomized to use an OT (i.e. procedural skill-based checklist) (OT+) or not (OT-) when observing other residents during a simulation bootcamp. The primary outcome was a composite score (total 60 points) evaluating CVC procedural skills rated immediately after the training. This score covers theoretical knowledge explored by multiple choice questions (MCQs) (/20), perceived improvement in knowledge and skills (/20), perceived impact on future professional life (/10) and satisfaction (/10). Measurements were repeated 1 month later. Residents in each group recorded the number of CVCs placed and their clinical outcomes (attempts, complications) during the first month of their clinical rotation using a logbook. RESULTS: Immediately after training, the composite score was similar between the two groups: 45.3 ± 4.2 (OT+, n = 49) and 44.4 ± 4.8 (OT-, n = 42) (p = 0.323). Analysis of sub-items also showed no difference. Results at 1 month were not different between groups. Analysis of the logbook showed no difference between groups. No serious complications were reported. CONCLUSIONS: The use of a procedural task-based OT by incoming anesthesia residents and used during CVC insertion simulation training was not associated with better learning outcomes, neither immediately after the session nor when re-evaluated 1 month later. The training at least once on simulator of all residents could limit the impact of OT. Further studies are necessary to define the place of OT in simulation training.

Deconstructing forearm casting task by videos with step-by-step simulation teaching improved performance of medical students: is making working student's memory work better similar to a process of artificial intelligence or just an improvement of the prefrontal cortex homunculus?

PURPOSE: To compare two teaching methods of a forearm cast in medical students through simulation, the traditional method (Trad) based on a continuous demonstration of the procedure and the task deconstruction method (Decon) with the procedure fragmenting into its constituent parts using videos. METHODS: During simulation training of the below elbow casting technique, 64 medical students were randomized in two groups. Trad group demonstrated the entire procedure without pausing. Decon group received step-wise teaching with educational videos emphasizing key components of the procedure. Direct and video evaluations were performed immediately after training (day 0) and at six months. Performance in casting was assessed using a 25-item checklist, a seven item global rating scale (GRS Performance), and a one item GRS (GRS Final Product). RESULTS: Fifty-two students (Trad n = 24; Decon n = 28) underwent both day zero and six month assessments. At day zero, the Decon group showed higher performance via video evaluation for OSATS (p = 0.035); GRS performance (p < 0.001); GRS final product (p < 0.001), and for GRS performance (p < 0.001) and GRS final product (p = 0.011) via direct evaluation. After six months, performance was decreased in both groups with ultimately no difference in performance between groups via both direct and video evaluation. Having done a rotation in orthopaedic surgery was the only independent factor associated to higher performance. CONCLUSIONS: The modified video-based version simulation led to a higher performance than the traditional method immediately after the course and could be the preferred method for teaching complex skills.

Comparison of multimodal active learning and single-modality procedural simulation for central venous catheter insertion for incoming residents in anesthesiology: a prospective and randomized study.

BACKGROUND: Active learning methods, including low-fidelity simulation, are useful but the incremental learning effect of each method is however limited. We designed this study to assess if combining flipped classroom and the modified Peyton's « 4-steps¼ method during procedural simulation (intervention group [IG]) would provide better learning results than simulation alone (control group [CG]) in the context of central venous catheter insertion training. METHODS: This prospective, single-center, and randomized study took place in 2017 in a single simulation center. All first year Anesthesiology residents of Ile de France area at the start of their residency were randomly included either in the IG or CG during a seminar aimed at providing initial procedural skills with low-fidelity simulation. A composite learning score which included knowledge MCQ and a questionnaire assessing satisfaction and value of the training session was recorded after training (primary outcome, /100). A randomized sub-group of learners of each group were video-recorded during central venous catheter insertion at the end of training and their skills were evaluated with validated tools, including a specific checklist and a global rating scale (GRS). RESULTS: Among 89 anesthesiology residents, 48 and 41 learners were randomized in the intervention and control groups respectively. Of the IG residents, 40/48 (83%) had read the learning material prior to the session. There was no significant difference regarding the composite outcome ([IG]= 81.1 vs [CG] = 80.5 /100 (p = 0.68)). Results of the post-session MCQ knowledge questionnaire were also non-significantly different. Residents were similarly satisfied and described a significant improvement of their knowledge and skills after training. Learners highly valued the training session as a mean to improve their future practice. No significant differences regarding checklist and GRS scores were observed. CONCLUSIONS: A multimodal active learning strategy of procedural learning did not provide better learning outcomes when compared to a traditional simulation method. In both groups, satisfaction was high and perception of the acquired theoretical and practical knowledge was improved after training.

Acute Visceral Pain in Rats: Vagal Nerve Block Compared to Bupivacaine Administered Intramuscularly.

BACKGROUND: Visceral and parietal peritoneum layers have different sensory innervations. Most visceral peritoneum sensory information is conveyed via the vagus nerve to the nucleus of the solitary tract (NTS). We already showed in animal models that intramuscular (i.m.) injection of local anesthetics decreases acute somatic and visceral pain and general inflammation induced by aseptic peritonitis. The goal of the study was to compare the effects of parietal block, i.m. bupivacaine, and vagotomy on spinal cord and NTS stimulation induced by a chemical peritonitis. METHODS: We induced peritonitis in rats using carrageenan and measured cellular activation in spinal cord and NTS under the following conditions, that is, a parietal nerve block with bupivacaine, a chemical right vagotomy, and i.m. microspheres loaded with bupivacaine. Proto-oncogene c-Fos (c-Fos), cluster of differentiation protein 11b (CD11b), and tumor necrosis factor alpha (TNF-α) expression in cord and NTS were studied. RESULTS: c-Fos activation in the cord was inhibited by nerve block 2 hours after peritoneal insult. Vagotomy and i.m. bupivacaine similarly inhibited c-Fos activation in NTS. Forty-eight hours after peritoneal insult, the number of cells expressing CD11b significantly increased in the cord (P = .010). The median difference in the effect of peritonitis compared to control was 30 cells (CI95, 13.5-55). TNF-α colocalized with CD11b. Vagotomy inhibited this microglial activation in the NTS, but not in the cord. This activation was inhibited by i.m. bupivacaine both in cord and in NTS. The median difference in the effect of i.m. bupivacaine added to peritonitis was 29 cells (80% increase) in the cord and 18 cells (75% increase) in the NTS. Our study underlines the role of the vagus nerve in the transmission of an acute visceral pain message and confirmed that systemic bupivacaine prevents noxious stimuli by inhibiting c-Fos and microglia activation. CONCLUSIONS: In rats receiving intraperitoneal carrageenan, i.m. bupivacaine similarly inhibited c-Fos and microglial activation both in cord and in the NTS. Vagal block inhibited activation only in the NTS. Our study underlines the role of the vagus nerve in the transmission of an acute visceral pain message and confirmed that systemic bupivacaine prevents noxious stimuli. This emphasizes the effects of systemic local anesthetics on inflammation and visceral pain.

Allowing more time to ILCOR Step A of neonatal resuscitation leads to better residents' task completion in simulated scenarios. A problem of time pressure?

BACKGROUND: Roughly 10% of newborns need help to complete the transition of birth. For these infants, international guidelines recommend supporting them using a 4-step procedure (A to D). Step A is an assessment time, which includes eight tasks and finishes by starting the positive pressure ventilation (PPV), if necessary (step B). The guidelines changed in 2015 and the allotted time was raised from 30 to 60 seconds for step A completion. This study aimed to assess if the reduced time constraint in step A could have an impact on 1st-year pediatric residents' performance to complete step A and if could lead to later initiation of step A. METHODS: Using video recordings of standardized neonatal scenarios over 6 years (3 before the change and 3 after), we assessed the ability of 1st-year pediatric residents of the Paris region to complete step A and initiate PPV in the allotted time in each period. Among the sessions, including at least five scenarios we evaluated all the PPV required scenarios executed for the first time by a dyad of 1st-year pediatric residents. RESULTS: Among 52 sessions, we included 104 scenarios (25 sessions and 50 scenarios before the change and 27 sessions and 54 scenarios after). PPV started roughly at 1-minute resuscitation in both periods, but completion of the tasks before PPV-start was significant. Only 12% of the dyad of residents executed the eight tasks before PPV initiation in the first period versus 54% in the second period (p < 0.0001). Additionally, the completion of the eight tasks of step A was significantly better during the second period (6 [6-7] vs. 8 [7-8] p < 0.001). CONCLUSIONS: These results could suggest that a reduced time constraint for step A imposed by the new Guidelines was associated with better performance.

Comparative value of a simulation by gaming and a traditional teaching method to improve clinical reasoning skills necessary to detect patient deterioration: a randomized study in nursing students.

BACKGROUND: Early detection and response to patient deterioration influence patient prognosis. Nursing education is therefore essential. The objective of this randomized controlled trial was to compare the respective educational value of simulation by gaming (SG) and a traditional teaching (TT) method to improve clinical reasoning (CR) skills necessary to detect patient deterioration. METHODS: In a prospective multicenter study, and after consent, 2nd year nursing students were randomized into two groups: Simulation by gaming "SG": the student played individually with a serious game consisting of 2 cases followed by a common debriefing with an instructor;Traditional Teaching "TT": the student worked on the same cases in text paper format followed by a traditional teaching course with a PowerPoint presentation by an instructor. CR skill was measured by script concordance tests (80 SCTs, score 0-100) immediately after the session (primary outcome) and on month later. Other outcomes included students' satisfaction, motivation and professional impact. RESULTS: One hundred forty-six students were randomized. Immediately after training, the SCTs scores were 59 ± 9 in SG group (n = 73) and 58 ± 8 in TT group (n = 73) (p = 0.43). One month later, the SCTs scores were 59 ± 10 in SG group (n = 65) and 58 ± 8 in TT group (n = 54) (p = 0.77). Global satisfaction and motivation were highly valued in both groups although significantly greater in the SG group (p < 0.05). The students declared that the training course would have a positive professional impact, with no difference between groups. CONCLUSIONS: In this study assessing nursing student CR to detect patient deterioration, no significant educational difference (SCT), neither immediate nor 1 month later, was observed between training by SG and the TT course. However, satisfaction and motivation were found to be greater with the use of SG. TRIAL REGISTRATION: ClinicalTrials.gov; NCT03428269. Registered 30 january 2018.

External Cardiac Massage Training of Medical Students: A Randomized Comparison of Two Feedback Methods to Standard Training.

BACKGROUND: The most recent recommendations support learning of external cardiac massage (ECM) through feedback devices. OBJECTIVES: The objective was to compare the effects on immediate and 3-month retention of ECM technical skills when using feedback devices compared with training without feedback as part of a half-day training session in medical students. METHODS: This randomized study was performed using the Resusci Anne QCPR manikin in 64 medical students. We compared the quality of ECM with nonfeedback training in the control group (group 1) vs. 2 feedback learning methods (group 2, PocketCPR and group 3, Skill Reporter each used with visual display available to the trainee). At the end of the training session and 3 months later, students performed chest compressions blindly during a 2-min assessment session. The median compression score was the primary outcome for assessing immediate and long-term retention. RESULTS: Regarding immediate retention, the median compression score was significantly lower in group 1 (23%) than in groups 2 (81%) and 3 (72%) (p < 0.05) with no difference between the 2 feedback methods. At 3 months, mean compression scores remained high but not significantly different between the 2 feedback groups. CONCLUSION: The use of a feedback device used for ECM training improves the quality of immediate retention of technical ECM skills compared with traditional teaching in medical students. At 3 months, the 2 groups with feedback retained a high level of performance. No significant difference could be demonstrated between the 2 feedback methods.

Does programmed intermittent epidural bolus improve childbirth conditions of nulliparous women compared with patient-controlled epidural analgesia?: A multicentre, randomised, controlled, triple-blind study.

BACKGROUND: Epidural analgesia may change the mechanics of childbirth. These changes are related to the concentration of the local anaesthetic used epidurally but probably also to its mode of delivery into the epidural space. OBJECTIVE: To determine whether the administration of programmed intermittent epidural boluses (PIEB) improves the mechanics of second-stage labour compared with patient-controlled epidural analgesia (PCEA) with a background infusion. DESIGN: A randomised, controlled, triple-blind study. SETTING: Multicentre study including four level III maternity units, January 2014 until June 2016. PATIENTS: A total of 298 nulliparous patients in spontaneous labour were randomised to a PIEB or PCEA group. INTERVENTION: After epidural initiation with 15 ml of 0.1% levobupivacaine containing 10 µg of sufentanil, patients received either an hourly bolus of 8 ml (PIEB) or a continuous rate infusion of 8 ml h (PCEA): the drug mixture used was levobupivacaine 0.1% and sufentanil 0.36 µg ml. MAIN OUTCOME MEASURES: The primary outcome was a composite endpoint of objective labour events: a posterior occiput position in the second stage, an occiput position at birth, waiting time at full cervical dilatation before active maternal pushing more than 3 h, maternal active pushing duration more than 40 min, and foetal heart rate alterations. Vaginal instrumental delivery rates, analgesia and motor blockade scores were also recorded. RESULTS: From the 298 patients randomised, data from 249 (124 PIEB, 125 PCEA) were analysed. No difference was found in the primary outcome: 48.0% (PIEB) and 45.5% (PCEA) of patients, P = 0.70. In addition, no difference was observed between the groups for each of the individual events of the composite endpoint, nor in the instrumental vaginal delivery rate, nor in the degree of motor blockade. Despite an equivalent volume of medication in the groups, a significantly higher analgesia score at full dilatation was observed in the PIEB group, odds-ratio = 1.9 (95% confidence interval, 1.0 to 3.5), P = 0.04. CONCLUSION: The mechanics of the second stage did not differ whether PIEB or PCEA was used. Analgesic conditions appeared to be superior with PIEB, especially at full dilation. TRIAL REGISTRATION: NCT01856166.

The Opiorphin Analog STR-324 Decreases Sensory Hypersensitivity in a Rat Model of Neuropathic Pain.

BACKGROUND: Neuropathic pain represents a therapeutic challenge, and treatments with increased efficacy and tolerability still need to be developed. Opiorphin protects endogenous enkephalins from degradation, potentiating enkephalin-dependent analgesia via the activation of opioid pathways. Enkephalins are natural ligands of opioid receptors, with strong affinity for δ-opioid receptors. Expression of functional δ-opioid receptors increases in sensory neurons after peripheral nerve injury in neuropathic pain models. In a postoperative pain model, opiorphin and its stable analog STR-324 have an analgesic potency comparable to that of morphine, but without adverse opioid-related side effects. Consequently, administration of endogenous opiorphin peptides or STR-324 might be effective in managing peripheral neuropathic pain. METHODS: In this study, STR-324 was administered intravenously over the course of 7 days to rats with mononeuropathy induced by L5-L6 spinal nerve root ligation. The rats exhibited mechanical allodynia, thermal hyperalgesia, and spontaneous pain-related behavior throughout the testing period. RESULTS: Here, we report that the continuous administration of STR-324 significantly reduced mechanical allodynia and spontaneous pain-related behavior from day 2 to day 7 in animals that received 10 or 50 µg/h of STR-324 as compared to placebo-treated animals (P < .00001 and P < .0011, respectively, for mechanical allodynia; P = .028 and P = .0049, respectively, for spontaneous pain-related behavior). In addition, STR-324 reduced the pain-evoked expression of spinal c-Fos in this model, demonstrating that it acts at least in part through inhibition of endogenous nociceptive pathways. CONCLUSIONS: These observations suggested that STR-324 may be an effective addition to the multimodal approach for treating clinical neuropathic pain.

Use of fresh frozen plasma: from the 2012 French guidelines to recent advances.

Fresh frozen plasma (FFP) is widely used by anesthetists and/or intensivists managing bleeding patients. In this context, two clinical situations with different benefit/risk ratio for FFP transfusion should be distinguished: moderate or controlled hemorrhage on one side, and massive hemorrhage on the other. In the former situation, administration of FFP is most often ineffective, associated with potential side effects (pulmonary complications, product shortage) and should therefore be restricted. In case of massive hemorrhage, transfusion of FFP, red blood cells and platelets using a ratio close to 1:1:1 is recommended based on a large number of studies. A goal-directed strategy, based on the utilization of point-of-care hemostatic devices, might be used as an alternative or in combination with this ratio-driven strategy.

Effect of Intralipid® on the Dose of Ropivacaine or Levobupivacaine Tolerated by Volunteers: A Clinical and Pharmacokinetic Study.

BACKGROUND: Rapid intravenous administration of lipid emulsion has become the standard treatment of severe local anesthetic systemic toxicity. This experiment in volunteers aimed at determining the effect of Intralipid® administration on the time to neurologic symptoms. METHODS: Ropivacaine or levobupivacaine was infused intravenously in 16 volunteers (8 mg/min up to 120 mg) with 120 ml Intralipid® 20% (Fresenius, Paris France) or placebo infused at T + 2 min). Each subject received all four treatments in a crossover manner. The infusion was stopped after the intended dose had been administered or on occurrence of incipient neurologic signs of toxicity. The primary outcome was time-to-event. In addition, blood ropivacaine and levobupivacaine concentrations were measured. RESULTS: The dose infused was not different whether volunteers received placebo (81.7 ± 22.3 vs. 80.8 ± 31.7 mg, ropivacaine vs. levobupivacaine) or Intralipid® (75.7 ± 29.1 vs. 69.4 ± 26.2 mg, ropivacaine vs. levobupivacaine), P = 0.755, Intralipid® versus placebo groups. Plasma concentrations were best modeled with an additional volume of distribution associated with Intralipid®. Simulations suggested that decreased peak concentrations would be seen if Intralipid® was given during a period of increasing concentrations after extravascular administration. CONCLUSIONS: At modestly toxic doses of ropivacaine or levobupivacaine, we were unable to find any effect of the infusion of Intralipid® on the time to early signs of neurologic toxicity in volunteers. Peak concentration was decreased by 26 to 30% in the subjects receiving Intralipid®. Simulations showed that Intralipid® might prevent the rapid increase of local anesthetic concentration after extravascular administration.

STR-324, a Stable Analog of Opiorphin, Causes Analgesia in Postoperative Pain by Activating Endogenous Opioid Receptor-dependent Pathways.

BACKGROUND: Opiorphin is a naturally occurring potent analgesic human peptide. It protects enkephalins from degradation and inhibits pain perception in various acute pain models via activation of endogenous opioid pathways. However, the efficacy of opiorphin continuous infusion and its chemically stable form, STR-324, in postoperative pain is unknown. METHODS: Using the Brennan model of plantar incision-induced hypersensitivity, the authors examined the postsurgical analgesic response to mechanical and thermal stimuli of 7-day continuously intravenously infused drugs (8 to 10 rats per group). Antinociception from opiorphin with reference to morphine and STR-324 was assessed. Spinal c-Fos expression and the involvement of opioid receptor-dependent pathways were investigated. The occurrence of respiratory and hemodynamic adverse effects of opiorphin was also tested. RESULTS: Intravenous infusion of opiorphin significantly reduced responses to mechanical stimuli from days 1 to 4 post surgical period at 143 to 175-kPa mean ranges compared with 23 to 30-kPa mean ranges for vehicle (P < 0.05). During the 3-day postoperative period, no respiratory rate, oxygen saturation, arterial pressure, or heart rate adverse effects were induced by opiorphin. STR-324 consistently inhibited mechanical and thermal hyperalgesia with similar potency as that of opiorphin. Mechanistic analyses demonstrated that the STR-324 antinociceptive effect was reversed by the opioid antagonist, naloxone. Also, STR-324 significantly reduced the number of pain-evoked spinal cFos-immunoreactive nuclei. CONCLUSION: Intravenous infusion of opiorphin and STR-324 produced significant antinociceptive effect in a postoperative pain model. This study demonstrates that STR-324 is effective in postoperative pain management due to its strong antihyperalgesic effects mediated via opioid-dependent antinociceptive pathways. Opiorphin analog should represent a new class of potent and safe analgesics.

A Comparison of Photoplethysmography Versus Esophageal Doppler for the Assessment of Cardiac Index During Major Noncardiac Surgery.

BACKGROUND: In this prospective observational study, we compared changes in cardiac index (CI) during fluid challenge using photoplethysmography (PPG; Nexfin™) (CIPPG) versus esophageal Doppler (ED) (CIED) in major noncardiac surgery patients. METHODS: Measurements were obtained when the attending anesthesiologist decided to perform a fluid challenge. Correlations with linear regression, Bland-Altman analysis, and analysis of covariance were performed. Trending ability was studied using 2 different methods: a 4-quadrant plot and a polar plot. RESULTS: Forty-three patients were analyzed with a total of 111 fluid challenges. There was a significant linear relationship between CI PPG and CI ED (r2 = 0.34; P < 0.001). The bias between the ED and the PPG measurements of CI was -0.114 (95% confidence interval [CI95], -1.9 to 1.7) L/min/m2, with a mean percentage error of 55%. The correlation between the changes in CI during a fluid challenge was significant (r2 = 0.25; P = 0.002). The concordance rate of directional changes (increase or decrease) of CI PPG and CI ED during fluid challenge was 67% (CI95, 57-75) for the whole data set and 85% (CI95, 70-94) with an exclusion zone of 15%. When considering ED as a reference, the sensitivity and specificity to give an additional bolus with PPG (increase in CI PPG ≥ 15%) were 35% (CI95, 19-55) and 90% (CI95, 81-96), respectively, with a positive predictive value of 58% (CI95, 33-80) and a negative predictive value of 78% (CI95, 68-86). CONCLUSIONS: In major noncardiac surgery patients, the evaluation of CI using PPG is not interchangeable with the evaluation of CI using ED. When considering the ED as an accurate device to assess changes in CI, PPG is not appropriate to assess the need for additional fluid administration. These results clearly indicate the limitations of PPG as an accurate device to track changes in CI compared with ED.

[CAESAREAN DELIVERY: STANDARDIZING THE PRACTICES]. / Césariennes: uniformiser les pratiques.

Caesarean delivery was performed in 20% of all deliveries in France in 2010 and this rate has remained unchanged during the last 10 years. Indications to perform this procedure are well defined, especially in case of scarred uterus, twin pregnancies, macrosomia or breech presentation. Surgical (haemorrhage, urinary or intestinal tract injury) and anaesthetic (hypotension after regional anaesthesia, difficult intubation and aspiration after general anaesthesia) complications may occur during the procedure. Complications may also be encountered in the early postoperative period (haemorrhage, infection, venous thromboembolism) but also on the long-term, such as placenta accreta or uterine rupture which may significantly impact obstetric outcomes. Enhanced recovery after surgery promotes early recovery and rapid convalescence. It simplifies nursing practice after surgery and is the first important step toward a patient- and family-centred care.

Goal-Directed Fluid Therapy Guided by Cardiac Monitoring During High-Risk Abdominal Surgery in Adult Patients: Cost-Effectiveness Analysis of Esophageal Doppler and Arterial Pulse Pressure Waveform Analysis.

BACKGROUND: Several minimally invasive techniques for cardiac output monitoring such as the esophageal Doppler (ED) and arterial pulse pressure waveform analysis (APPWA) have been shown to improve surgical outcomes compared with conventional clinical assessment (CCA). OBJECTIVE: To evaluate the cost-effectiveness of these techniques in high-risk abdominal surgery from the perspective of the French public health insurance fund. METHODS: An analytical decision model was constructed to compare the cost-effectiveness of ED, APPWA, and CCA. Effectiveness data were defined from meta-analyses of randomized clinical trials. The clinical end points were avoidance of hospital mortality and avoidance of major complications. Hospital costs were estimated by the cost of corresponding diagnosis-related groups. RESULTS: Both goal-directed therapy strategies evaluated were more effective and less costly than CCA. Perioperative mortality and the rate of major complications were reduced by the use of ED and APPWA. Cost reduction was mainly due to the decrease in the rate of major complications. APPWA was dominant compared with ED in 71.6% and 27.6% and dominated in 23.8% and 20.8% of the cases when the end point considered was "major complications avoided" and "death avoided," respectively. Regarding cost per death avoided, APPWA was more likely to be cost-effective than ED in a wide range of willingness to pay. CONCLUSIONS: Cardiac output monitoring during high-risk abdominal surgery is cost-effective and is associated with a reduced rate of hospital mortality and major complications, whatever the device used. The two devices evaluated had negligible costs compared with the observed reduction in hospital costs. Our comparative studies suggest a larger effect with APPWA that needs to be confirmed by further studies.