Responsiveness of multiple patient-reported outcome measures for acute postsurgical pain: primary results from the international multi-centre PROMPT NIT-1 study.

BACKGROUND: Postsurgical outcome measures are crucial to define the efficacy of perioperative pain management; however, it is unclear which are most appropriate. We conducted a prospective study aiming to assess sensitivity-to-change of patient-reported outcome measures assessing the core outcome set of domains pain intensity (at rest/during activity), physical function, adverse events, and self-efficacy. METHODS: Patient-reported outcome measures were assessed preoperatively, on day 1 (d1), d3, and d7 after four surgical procedures (total knee replacement, breast surgery, endometriosis-related surgery, and sternotomy). Primary outcomes were sensitivity-to-change of patient-reported outcome measures analysed by correlating their changes (d1-d3) with patients' global impression of change and patients' specific impression of change items as anchor criteria. Secondary outcomes included identification of baseline and patient characteristic variables explaining variance in change for each of the scales and descriptive analysis of various patient-reported outcome measures from different domains and after different surgeries. RESULTS: Of 3322 patients included (18 hospitals, 10 countries), data from 2661 patients were analysed. All patient-reported outcome measures improved on average over time; the median calculated sensitivity-to-change for all patient-reported outcome measures (overall surgeries) was 0.22 (range: 0.07-0.31, scale: 0-10); all changes were independent of baseline data or patient characteristics and similar between different procedures. CONCLUSIONS: Pain-related patient-reported outcome measures have low to moderate sensitivity-to-change; those showing higher sensitivity-to-change from the same domain should be considered for inclusion in a core outcome set of patient-reported outcome measures to assess the effectiveness and efficacy of perioperative pain management.

Chronic postsurgical pain: A European survey.

BACKGROUND: Chronic postsurgical pain (CPSP) is a clinical problem, and large prospective studies are needed to determine its incidence, characteristics, and risk factors. OBJECTIVE: To find predictive factors for CPSP in an international survey. DESIGN: Observational study. SETTING: Multicentre European prospective observational trial. PATIENTS: Patients undergoing breast cancer surgery, sternotomy, endometriosis surgery, or total knee arthroplasty (TKA). METHOD: Standardised questionnaires were completed by the patients at 1, 3, and 7 days, and at 1, 3, and 6 months after surgery, with follow-up via E-mail, telephone, or interview. MAIN OUTCOME MEASURE: The primary goal of NIT-1 was to propose a scoring system to predict those patient likely to have CPSP at 6 months after surgery. RESULTS: A total of 3297 patients were included from 18 hospitals across Europe and 2494 patients were followed-up for 6 months. The mean incidence of CPSP at 6 months was 10.5%, with variations depending on the type of surgery: sternotomy 6.9%, breast surgery 7.4%, TKA 12.9%, endometriosis 16.2%. At 6 months, neuropathic characteristics were frequent for all types of surgery: sternotomy 33.3%, breast surgery 67.6%, TKA 42.4%, endometriosis 41.4%. One-third of patients experienced CPSP at both 3 and 6 months. Pre-operative pain was frequent for TKA (leg pain) and endometriosis (abdomen) and its frequency and intensity were reduced after surgery. Severe CPSP and a neuropathic pain component decreased psychological and functional wellbeing as well as quality of life. No overarching CPSP risk factors were identified. CONCLUSION: Unfortunately, our findings do not offer a new CPSP predictive score. However, we present reliable new data on the incidence, characteristics, and consequences of CPSP from a large European survey. Interesting new data on the time course of CPSP, its neuropathic pain component, and CPSP after endometriosis surgery generate new hypotheses but need to be confirmed by further research. TRIAL REGISTRATION: clinicaltrials.gov ID: NCT03834922.

Towards better predictive models of chronic post-surgical pain: fitting to the dynamic nature of the pain itself.

Chronic post-surgical pain predictive scores exist, but none has yet demonstrated an impact on patient care. Van Driel and colleagues offer an additional perspective on early postoperative detection of patient at risk of chronic post-surgical pain to enable early interventions in prevention and treatment. The authors derived and validated a model based on four easily obtainable predictors that could help clinicians assess and treat patients at risk. Additional work is needed to prove reliability and clinical benefit of chronic post-surgical pain prediction and intervention.

Perioperative adverse events attributed to α2-adrenoceptor agonists in patients not at risk of cardiovascular events: systematic review and meta-analysis.

BACKGROUND: Several systematic reviews have reported the benefits of perioperative α2-adrenoceptor agonist use for various conditions, but safety evidence is poorly documented. METHODS: We performed a systematic review focusing on adverse events. We searched the MEDLINE, Embase, LILACS, Cochrane, and Clinical Trials Register databases for RCTs comparing the effects of α2-adrenoceptor agonists and placebo during non-cardiovascular surgery under general anaesthesia, for any indication, in patients not at risk of cardiovascular events. The primary outcome was the incidence of severe adverse events during or after α2-adrenoceptor agonist administration. The secondary endpoints were other adverse events. A meta-analysis was carried out on the combined data. Evidence quality was rated by the Grading of Recommendations Assessment, Development and Evaluation method. RESULTS: We included 56 studies (4868 patients). Our review, based on moderate-quality evidence, revealed that hypotension occurred frequently during the preoperative and postoperative periods, for both clonidine and dexmedetomidine. Bradycardia was reported only with dexmedetomidine. In contrast, dexmedetomidine seemed to protect against intraoperative hypertension and tachycardia. Subgroup analysis suggested that the risk of hypotension and bradycardia persisted after cessation of treatment. Interestingly, intraoperative hypotension and postoperative bradycardia were not observed with a bolus dosage of dexmedetomidine less than 0.5 µg kg-1 or with continuous administration alone. CONCLUSIONS: Pooled data for the incidence of adverse events associated with use of α2-adrenoceptor agonists in various perioperative contexts provide high-confidence evidence for a risk of hypotension and bradycardia, and protective effects against hypertension and tachycardia. PROTOCOL REGISTRATION: CRD42017071583.

Functional recovery after knee arthroplasty with regional analgesia: A systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Regional analgesia (RA) has been widely evaluated for pain relief after total knee arthroplasty (TKA). Its impact on functional recovery is less well known. OBJECTIVES: To evaluate the functional benefits of RA after TKA. DESIGN: Systematic review with a random-effects meta-analysis of randomised controlled trials comparing LRA with systemic analgesia on function in adults undergoing TKA for osteoarthritis. DATABASE SOURCES: MEDLINE, EMBASE, LILAC, Cochrane, CTRD databases. OUTCOMES: Length of stay (LOS) in hospital and early knee flexion range of motion (ROM), early and long-term knee function, serious adverse effects. RESULTS: Twenty-three studies (1246 patients) were included. LOS was significantly shorter for RA than for systemic analgesia (0.90 days, 95% confidence interval 0.3 to 1.4). Subgroup analyses found that only infiltration analgesia decreased the LOS. ROM during the first week was significantly higher for all techniques of RA than for systemic analgesia (9.23°, 95% confidence interval 4.6 to 13.9). No impact of regional analgesia techniques on global function in the longer term was demonstrated. No difference in serious adverse effects was found between RA and systemic analgesia. CONCLUSION: RA techniques compared with systemic analgesia have a beneficial impact on the LOS and the ROM achieved in the early postoperative period. Global function in the longer term after surgery seems unaffected by peri-operative RA. TRIAL REGISTRATION: CRD42014013995.

Hyperalgesia induced by low-dose opioid treatment before orthopaedic surgery: An observational case-control study.

BACKGROUND: Chronic pain and opioid consumption may trigger diffuse hyperalgesia, but their relative contributions to pain vulnerability remain unclear. OBJECTIVES: To assess preoperative opioid-induced hyperalgesia and its postoperative clinical consequences in patients with chronic pain scheduled for orthopaedic surgery. DESIGN: A prospective observational study. SETTINGS: Raymond Poincare teaching hospital. PATIENTS: Adults with or without long-term opioid treatment, scheduled for orthopaedic surgery. PRIMARY OUTCOME MEASURE: Preoperative hyperalgesia was assessed with eight quantitative sensory tests, in a pain-free zone. SECONDARY OUTCOME MEASURES: Postoperative morphine consumption and pain intensity were evaluated using a numerical rating scale (NRS) in the recovery room and during the first 72 h. RESULTS: We analysed results from 68 patients (28 opioid-treated patients and 40 controls). Mean daily opioid consumption was 42 ±â€Š25 mg of morphine equivalent. The opioid-treated group displayed significantly higher levels of preoperative hyperalgesia in three tests: heat tolerance threshold (47.1°C vs. 48.4°C; P = 0.045), duration of tolerance to a 47°C stimulus (40.2 vs. 51.1 s; P = 0.03) and mechanical temporal summation [1.79 vs. 1.02 (ΔNRS10-1); P = 0.036]. Patients in the opioid-treated group consumed more morphine (19.1 vs. 9.38 mg; P = 0.001), had a higher pain intensity (7.6 vs. 5.5; P = 0.001) in the recovery room and a higher cumulative morphine dose at 72 h (39.8 vs. 25.6 mg; P = 0.02). CONCLUSION: Chronic pain patients treated with low doses of opioid had hyperalgesia before surgery. These results highlight the need to personalise the management of patients treated with opioids before surgery. TRIAL REGISTRATION: ID-RCB 2011-A00304-37.

Ethical procedures and patient consent differ in Europe.

BACKGROUND: Research ethics approvals, procedures and requirements for institutional research ethics committees vary considerably by country and by type of organisation. OBJECTIVE: To evaluate the requirements and procedures of research ethics committees, details of patient information and informed consent based on a multicentre European trial. DESIGN: Survey of European hospitals participating in the prospective observational study on chronic postsurgical pain (euCPSP) using electronic questionnaires. SETTING: Twenty-four hospitals in 11 European countries. PARTICIPANTS: From the 24 hospitals, 23 local investigators responded; 23 answers were analysed. OUTCOME MEASURES: Comparison of research ethics procedures and committee requirements from the perspective of clinical researchers. Comparison of the institutions' procedures regarding patient information and consent. Description of further details such as costs and the duration of the approval process. RESULTS: The approval process lasted from less than 2 weeks up to more than 2 months with financial fees varying between 0 and 575 &OV0556;. In 20 hospitals, a patient information sheet of variable length (half page up to two pages) was provided. Requirements for patients' informed consent differed. Written informed consent was mandatory at 12, oral at 10 and no form of consent at one hospital. Details such as enough time for consideration, possibility for withdrawal and risks/benefits of participation were provided in 25 to 30% of the institutions. CONCLUSION: There is a considerable variation in the administrative requirements for approval procedures by research ethics committees in Europe. This results in variation of the extent of information and consent procedures for the patients involved. TRIAL REGISTRATION: euCPSP in Clinicaltrials.gov identifier: NCT01467102; PAIN-OUT in Clinicaltrials.gov identifier: NCT02083835.

Chronic postsurgical pain in Europe: An observational study.

BACKGROUND: Chronic postsurgical pain (CPSP) is an important clinical problem. Prospective studies of the incidence, characteristics and risk factors of CPSP are needed. OBJECTIVES: The objective of this study is to evaluate the incidence and risk factors of CPSP. DESIGN: A multicentre, prospective, observational trial. SETTING: Twenty-one hospitals in 11 European countries. PATIENTS: Three thousand one hundred and twenty patients undergoing surgery and enrolled in the European registry PAIN OUT. MAIN OUTCOME MEASURES: Pain-related outcome was evaluated on the first postoperative day (D1) using a standardised pain outcome questionnaire. Review at 6 and 12 months via e-mail or telephonic interview used the Brief Pain Inventory (BPI) and the DN4 (Douleur Neuropathique four questions). Primary endpoint was the incidence of moderate to severe CPSP (numeric rating scale, NRS ≥3/10) at 12 months. RESULTS: For 1044 and 889 patients, complete data were available at 6 and 12 months. At 12 months, the incidence of moderate to severe CPSP was 11.8% (95% CI 9.7 to 13.9) and of severe pain (NRS ≥6) 2.2% (95% CI 1.2 to 3.3). Signs of neuropathic pain were recorded in 35.4% (95% CI 23.9 to 48.3) and 57.1% (95% CI 30.7 to 83.4) of patients with moderate and severe CPSP, respectively. Functional impairment (BPI) at 6 and 12 months increased with the severity of CPSP (P < 0.01) and presence of neuropathic characteristics (P < 0.001). Multivariate analysis identified orthopaedic surgery, preoperative chronic pain and percentage of time in severe pain on D1 as risk factors. A 10% increase in percentage of time in severe pain was associated with a 30% increase of CPSP incidence at 12 months. CONCLUSION: The collection of data on CPSP was feasible within the European registry PAIN OUT. The incidence of moderate to severe CPSP at 12 months was 11.8%. Functional impairment was associated with CPSP severity and neuropathic characteristics. Risk factors for CPSP in the present study were chronic preoperative pain, orthopaedic surgery and percentage of time in severe pain on D1. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01467102.

Guidelines on perioperative optimization protocol for the adult patient 2023.

OBJECTIVE: The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS: The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS: Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Management of acute allergic reactions by dispatching physicians in a Medical Emergency Dispatch Centre.

BACKGROUND: Acute allergic reactions often occur in out-of-hospital settings, and some of these reactions may cause death in the short term. However, initial diagnosis, management and processing of acute allergic reactions by Medical Emergency Dispatch Centres are not documented. The aim of the present study was to describe acute allergic reactions and their management by a Medical Emergency Dispatch Centre. METHODS: A prospective study was conducted from 20 August 2006 to 5 November 2006 on incoming calls for acute allergic reactions to the Medical Emergency Dispatch Centre for the Hauts de Seine (Paris West suburb, France). The agreement between initial diagnosis (made by dispatching physician) and final diagnosis (made by the physician who later examined the patient), and between initial and final severity, were evaluated using Cohen's weighted κ coefficient. RESULTS: 210 calls were included. The diagnoses made by the dispatching physician were: in 58.1% of cases urticaria, in 23.8% angioedema, in 13.3% laryngeal oedema, and in 1.9% anaphylactic shock. The agreement between initial and final diagnoses was evaluated by a κ coefficient at 0.44 (95% CI 0.26 to 0.61) and the agreement between initial and final severity was evaluated using a κ coefficient at 0.37 (95% CI 0.24 to 0.50). CONCLUSIONS: Only moderate agreement is highlighted between the initial severity assessed by the dispatching physician and the final severity assessed by the physician later examining the patient. This demonstrates the need to develop a tool for assessing severity of acute allergic reactions for dispatching physicians in Medical Emergency Dispatch Centres.

Qualitative analysis of the organisational response of a university hospital during the first wave of the COVID-19 crisis.

BACKGROUND: The COVID-19 pandemic has required urgent organisational and managerial adaptation, with hospital medical and administrative leaders under considerable pressure. METHODS: At a single French university hospital, we performed a sociological analysis of management adaptation by medical and administrative leaders during the first wave of the COVID-19 crisis. Two sociologists performed interviews with representative members of staff from all the structures involved in managing the crisis to analyse adaptation and the solutions found during this period. RESULTS: The answers collected during interviews were classified into three main topics describing the organisational adaptations of the hospital staff during the COVID-19 crisis: (1) exceptional mobilisation and collaboration; (2) crisis management based primarily on the principle of subsidiarity; and (3) survival of the administrative structure with interventions to support caregivers. CONCLUSION: This study, focusing on a single hospital, identified a number of factors associated with successful mobilisation in the very specific conditions of this viral pandemic.

Paravertebral block for the prevention of chronic postsurgical pain after breast cancer surgery.

Patients frequently report chronic postsurgical pain (CPSP) after breast cancer surgery (BCS). The paravertebral block (PVB) is an effective technique to reduce acute postoperative pain after BCS, but its efficacy in preventing CPSP is unclear. This meta-analysis evaluates the efficacy of PVB in preventing CPSP after BCS. We searched Medline, Embase, CENTRAL, Database of Abstracts of Reviews of Effects, ClinicalTrials.gov, and WHO International Clinical Trials Registry Platform for studies comparing PVB with control for CPSP prevention after BCS, from inception to April 2020. The primary outcome was CPSP at 6 months, and the secondary outcomes were CPSP at 3 and 12 months, chronic postsurgical neuropathic pain (CPSNP) at 6 months, and PVB-related complications. Data were pooled and analyzed with a random-effects model, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system was used to evaluate the certainty of evidence. A total of 12 studies were included in the study; data for the 6-month time point from 7 studies (2161 patients) were analyzed, and no difference was found between PVB and control in terms of efficacy in preventing CPSP after BCS (risk ratio (RR) 0.82 (95% CI 0.62 to 1.08)), with a moderate quality of evidence according to the GRADE system. Similar results were obtained at 3 and 12 months (RR 0.78 (95% CI 0.57 to 1.06), RR 0.45 (95% CI 0.14 to 1.41), respectively). Data for the 12-month time point from seven studies (2087 patients) were analyzed and showed that PVB protected against CPSNP, with low quality of evidence (RR 0.51 (95% CI 0.31 to 0.85)). In conclusion, CPSP was not found significantly prevented by PVB after BCS despite the limits in the included studies; nevertheless, PVB could prevent CPSNP by impacting the transition from acute to chronic pain.

Opioid-Free Anesthesia Benefit-Risk Balance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Opioid-free anesthesia (OFA) is used in surgery to avoid opioid-related side effects. However, uncertainty exists in the balance between OFA benefits and risks. We searched for randomized controlled trials (RCTs) comparing OFA to opioid-based anesthesia (OBA) in five international databases. The co-primary outcomes were postoperative acute pain and morphine consumption at 2, 24, and 48 h. The secondary outcomes were the incidence of postoperative chronic pain, hemodynamic tolerance, severe adverse effects, opioid-related adverse effects, and specific adverse effects related to substitution drugs. Overall, 33 RCTs including 2209 participants were assessed. At 2 h, the OFA groups had lower pain scores at rest MD (0.75 (-1.18; -0.32)), which did not definitively reach MCID. Less morphine was required in the OFA groups at 2 and 24 h, but with very small reductions: 1.61 mg (-2.69; -0.53) and -1.73 mg (p < 0.05), respectively, both not reaching MCID. The reduction in PONV in the OFA group in the PACU presented an RR of 0.46 (0.38, 0.56) and an RR of 0.34 (0.21; 0.56), respectively. Less sedation and shivering were observed in the OFA groups with an SMD of -0.81 (-1.05; -0.58) and an RR of 0.48 (0.33; 0.70), respectively. Quantitative analysis did not reveal differences between the hemodynamic outcomes, although severe side effects have been identified in the literature. No clinically significant benefits were observed with OFA in terms of pain and opioid use after surgery. A clear benefit of OFA use was observed with respect to a reduction in PONV. However, more data on the safe use of OFAs should be collected and caution should be taken in the development of OFA.

Perceived stress, anxiety and depressive symptoms among anaesthesia and intensive care residents: A French national survey.

BACKGROUND: Mental health and well-being is a significant problem for medical students in training. In this study, we aim to estimate the prevalence of anxiety and depressive symptoms, burnout and psychosocial distress in French anaesthesia and intensive care residents. METHODS: A national online observational study used validated questionnaires (Hospital Anxiety and Depression Scale (HADS), Copenhagen Burnout Inventory (CBI), Perceived Stress Scale (PSS) and work-related questions (work-hours per week, night shift per month, safety rest after night shift, average time to start and end work, break time and time for lunch) to assess mental health and well-being of French residents in anaesthesia and intensive care. RESULTS: We obtained 519 answers (22.5% of 2302 students), 55% of respondents working in anaesthesia, 41% in intensive care at the time of study. Residents describe certain symptomatology in anxiety (19.8%) and depressive symptoms (7.8%). PSS identifies a perceived high stress (score > 27) for 55.7% of the subjects. The CBI questionnaire identifies 205 (38.9%) residents undergoing burnout, 80.7% working more than 48 h per week and 39.1% more than 60 h. The duration of work per week (> 50 h), gender (female) and on-going training in intensive care are independent risk factors of psychological suffering. Lifestyle and level of training are not statistically identified risk factors. CONCLUSION: This first online survey of French anaesthesia and intensive care residents reveals a significant frequency of anxiety and depressive symptoms, burnout and a link to potential targets of improvement in work conditions mainly related to the number of work hours per week.

Two per cent alcoholic chlorhexidine versus alcoholic five per cent povidone-iodine for the prevention of perineural catheter colonisation: The CHLOVEPI randomised, controlled trial.

BACKGROUND: Multimodal analgesia, including a regional technique using perineural catheters (PNCs), is recommended for the treatment of moderate-to-severe acute postoperative pain. Perineural catheters are at risk of bacterial colonisation. In this study, we compared the cutaneous antiseptic efficacy of 2% alcoholic chlorhexidine and povidone-iodine-alcohol for preventing the bacterial colonisation of PNCs in orthopaedic surgery. METHODS: We performed a randomised, controlled trial, comparing two cutaneous antisepsis strategies, one based on 2% alcoholic chlorhexidine and the other on povidone-iodine-5% alcohol, for placed PNCs before orthopaedic surgery. The primary endpoint was the incidence of catheter bacterial colonisation (threshold > 1000 colony-forming units/ml). The secondary endpoints were the incidence of catheter-related infections and the adverse effects of the antiseptic solutions. RESULTS: From November 2016 to May 2018, we included 113 patients in this study. The use of alcoholic chlorhexidine was associated with a lower incidence of catheter colonisation (15.5% (n = 9) versus 32.7% (n = 18); OR: 0.28 [0.09-0.77], p = 0.01). No catheter-related infections or adverse effects of antiseptic solutions were observed in either group. The risk factors associated with colonisation were a duration of catheter use ≥ 3 days (p = 0.04) and obesity (p = 0.005). The most frequently identified bacterium was Staphylococcus epidermidis. CONCLUSION: Skin disinfection with 2% alcoholic chlorhexidine decreases bacterial colonisation rates for placed perineural catheters.

Limited impact of a top-down approach to improve enhanced recovery programme in French university hospitals: a before-after retrospective survey.

BACKGROUND: Enhanced recovery programme (ERP) after surgery needs development in Assistance Publique Hôpitaux de Paris (APHP). METHODS: A retrospective before-and-after study was performed in 2015 and 2017 on three surgical models (total knee arthroplasty (TKA), colectomy and hysterectomy) in 17 hospitals including 29 surgical departments. Data were collected in one control intervention (total hip arthroplasty (THA), gastrectomy and ovariectomy). In 2016, Massive Open Online Course on ERP and a day meeting information were developed by APHP. A national update on ERP was also organized by HAS and a regional professional partnership programme was started. Primary outcomes were length of stay (LOS) and complications after surgery. Data on ERP items were collected in the patients' chart and in anaesthetist and surgeon interview. Seventy percent application rate reflects application of ERP procedure. RESULTS: 1321 patient's files were analysed (812 in 2015 and 509 in 2017). The LOS (mean (SD)) is reduced by 1.6 day for TKA (2015, 8.7 (6.7) versus 7.1 (3.4) in 2017; p<0.001) but stable for colectomy and hysterectomy. Incidence of severe complications after surgery is unchanged in all types of surgical models. For TKA and hysterectomy respectively applied items of ERP (i.e. >70% application) increased respectively from 5 to 7 out of 17 and 16 in 2015 and 2017. For colectomy, they were stable at 6 out of 21 in 2015 and 2017. The mean application rates of ERP items stayed below 50% in all cases in 2017. The LOS was negatively correlated with ERP items' application when data collected in 2015 and 2017 were analysed together. CONCLUSION: ERP application did not significantly improved between 2015 and 2017 for three surgical models after an institutional information and diffusion of recommendations in 29 surgical departments of seventeen French University hospitals underlining the limit of a top-down approach.

Guidelines on muscle relaxants and reversal in anaesthesia.

OBJECTIVES: To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS: The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS: The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION: Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

Pain-related functional interference in patients with chronic neuropathic postsurgical pain: an analysis of registry data.

Although chronic postsurgical pain (CPSP) is a major health care problem, pain-related functional interference has rarely been investigated. Using the PAIN OUT registry, we evaluated patients' pain-related outcomes on the first postoperative day, and their pain-related interference with daily living (Brief Pain Inventory) and neuropathic symptoms (DN4: douleur neuropathique en 4 questions) at 6 months after surgery. Endpoints were pain interference total scores (PITS) and their association with pain and DN4 scores. Furthermore, possible risk factors associated with impaired function at M6 were analyzed by ordinal regression analysis with PITS groups (no to mild, moderate, and severe interference) as a dependent three-stage factor. Odds ratios with 95% confidence intervals were calculated. Of 2322 patients, 15.3% reported CPSP with an average pain score ≥3 (numeric rating scale 0-10). Risk for a higher PITS group increased by 190% (odds ratio [95% confidence interval]: 2.9 [2.7-3.2]; P < 0.001) in patients with CPSP, compared to without CPSP. A positive DN4 independently increased risk by 29% (1.3 [1.12-1.45]; P < 0.001). Preexisting chronic pain (3.6 [2.6-5.1]; P < 0.001), time spent in severe acute pain (2.9 [1.3-6.4]; P = 0.008), neurosurgical back surgery in males (3.6 [1.7-7.6]; P < 0.001), and orthopedic surgery in females (1.7 [1.0-3.0]; P = 0.036) were the variables with strongest association with PITS. Pain interference total scores might provide more precise information about patients' outcomes than pain scores only. Because neuropathic symptoms increase PITS, a suitable instrument for their routine assessment should be defined.

Pain Trajectory After Ankle Surgeries for Osteoarthritis.

BACKGROUND:: The pain trajectory after ankle surgeries for osteoarthritis is relevant to describe. The purpose of this prospective study was to describe pain after ankle surgery and explore the link between perioperative factors and the development of postoperative pain. METHODS:: Duration, severity, type of preoperative pain, psychological distress, opioid consumption, and type of surgery were evaluated in 49 patients who were followed for 18 months. Acute postoperative pain in the first 10 days after surgery was modeled by a pain trajectory. Univariate analysis was conducted to identify predictors of acute pain trajectory and chronic pain. RESULTS:: Eighty-seven percent of patients had preoperative chronic pain, 34% had a high postoperative pain trajectory, 44% of whom reported chronic pain at 18 months. The patients who developed a high acute pain trajectory had higher preoperative opioid consumption (50% vs 19.4%, P = .04), a higher incidence of preoperative neuropathic pain (68.8% vs 32.3%, P = .02), a higher brief pain inventory score (51.5 vs 34, P = .01), and a higher psychological distress score (8 vs 3, P = .002). The patients who developed chronic pain had a higher brief pain inventory score (42 vs 33, P = .04), a higher psychological distress score (6 vs 4, P = .04), and a higher preoperative pain intensity (8 vs 6, P = .008). No association was found between the type of ankle surgery and pain. CONCLUSION:: Patients with psychological distress and more severe preoperative pain were more at risk to develop acute pain and chronic pain after ankle surgery regardless of the surgery performed. LEVEL OF EVIDENCE:: Level II, prospective comparative study.