Revision of expert panel's guidelines on postoperative pain management.

The French Society of Anaesthesia and Intensive Care Medicine (SFAR) published experts' guidelines on the care of postoperative pain. This was an update of the 2008 guidelines. Fourteen experts analysed the literature (PubMed™, Cochrane™) on questions that had not been treated in the previous guidelines, or to modify the guidelines following new data in the published literature. The used method is invariably the GRADE© method, which guarantees a rigorous work. Seventeen recommendations were formalised on the assessment of perioperative pain, and most particularly in non-communicating patients, on opioid and non-opioid analgesics and on anti-hyperalgesic drugs, such as ketamine and gabapentinoids, as well as on local and regional anaesthesia. The concept of vulnerability and therefore the identification of the most fragile patients in terms of analgesics requirements were specified. Because of the absence of sufficient data or new information, no recommendation was made about analgesia monitoring, the procedures for the surveillance of patients in conventional care structures, or perinervous or epidural catheterism.

Management of bleeding and emergency invasive procedures in patients on dabigatran: Updated guidelines from the French Working Group on Perioperative Haemostasis (GIHP) - September 2016.

In 2013, the GIHP published guidelines for the management of severe haemorrhages and emergency surgery. This update applies to patients treated with dabigatran, with a bleeding complication or undergoing an urgent invasive procedure. It includes how to handle the available specific antidote (idarucizumab), when to measure dabigatran plasmatic concentration and when to use non-specific measures in these situations. It also includes guidelines on how to perform regional anaesthesia and analgesia procedures.

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.

Perioperative use of gabapentinoids in France. Mismatch between clinical practice and scientific evidence.

BACKGROUND: Gabapentinoids have governmental health agency approval for "chronic neuropathic pain." Over the last decade, however, the perioperative prescription of gabapentinoids has become more popular among anaesthesiologists due to their anxiolytic and antihyperalgesic proprieties, despite weak scientific evidence supporting the risk/benefit ratio for this indication. METHODS: Our aim was to extensively describe the use of perioperative gabapentinoids by French anaesthesiologists. An online questionnaire was sent to the French Society of Anaesthesiology members. The questionnaire, focusing on gabapentinoid prescriptions, included questions on demographic data, patient conditions and types of surgeries, mode of prescription, motives and presumed side effects (dizziness, confusion, desaturation and visual disorders). RESULTS: Five hundred and eight questionnaires were analysed, among which 70% reported gabapentinoid use. Twenty-five percent of prescribers stated using gabapentinoids in all types of surgeries, 30% in outpatient surgeries and 46% in combination with regional anaesthesia. In 66% of the cases, preoperative and postoperative prescriptions were combined. Sedation, dizziness and visual disturbance were expected side effects according to 68%, 45% and 20% of anaesthesiologists, respectively. Reported reasons in favor of gabapentinoid prescription were prevention of chronic pain (93%), expected high postoperative acute pain, i.e. painful surgeries (91%), a history of chronic pain (72%) and patient opioid dependence (72%). DISCUSSION: French anaesthesiologists have recently included gabapentinoids in the multimodal management of postoperative pain but they are unaware of certain frequent side effects. Moreover, their expectations about the prevention of chronic pain are not validated. Our survey is a call to moderate the systematic prescription of these drugs in the perioperative period.

Management of direct oral anticoagulants in patients undergoing elective surgeries and invasive procedures: Updated guidelines from the French Working Group on Perioperative Hemostasis (GIHP) - September 2015.

Since 2011, data on patients exposed to direct oral anticoagulants (DOAs) while undergoing invasive procedures have accumulated. At the same time, an increased hemorrhagic risk during perioperative bridging anticoagulation without thrombotic risk reduction has been demonstrated. This has led the GIHP to update their guidelines published in 2011. For scheduled procedures at low bleeding risk, it is suggested that patients interrupt DOAs the night before irrespective of type of drug and to resume therapy six hours or more after the end of the invasive procedure. For invasive procedures at high bleeding risk, it is suggested to interrupt rivaroxaban, apixaban and edoxaban three days before. Dabigatran should be interrupted according to the renal function, four days and five days if creatinine clearance is higher than 50mL/min and between 30 and 50mL/min, respectively. For invasive procedures at very high bleeding risk such as intracranial neurosurgery or neuraxial anesthesia, longer interruption times are suggested. Finally, bridging with parenteral anticoagulation and measurement of DOA concentrations can no longer routinely be used.

The effects of intraoperative lung protective ventilation with positive end-expiratory pressure on blood loss during hepatic resection surgery: A secondary analysis of data from a published randomised control trial (IMPROVE).

BACKGROUND: During high-risk abdominal surgery the use of a multi-faceted lung protective ventilation strategy composed of low tidal volumes, positive end-expiratory pressure (PEEP) and recruitment manoeuvres, has been shown to improve clinical outcomes. It has been speculated, however, that mechanical ventilation using PEEP might increase intraoperative bleeding during liver resection. OBJECTIVE: To study the impact of mechanical ventilation with PEEP on bleeding during hepatectomy. DESIGN: Post-hoc analysis of a randomised controlled trial. SETTING: Seven French university teaching hospitals from January 2011 to August 2012. PARTICIPANTS: Patients scheduled for liver resection surgery. INTERVENTION: In the Intraoperative Protective Ventilation trial, patients scheduled for major abdominal surgery were randomly assigned to mechanical ventilation using low tidal volume, PEEP between 6 and 8  cmH2O and recruitment manoeuvres (lung protective ventilation strategy) or higher tidal volume, zero PEEP and no recruitment manoeuvres (non-protective ventilation strategy). MAIN OUTCOME AND MEASURE: The primary endpoint was intraoperative blood loss volume. RESULTS: A total of 79 (19.8%) patients underwent liver resections (41 in the lung protective and 38 in the non-protective group). The median (interquartile range) amount of intraoperative blood loss was 500 (200 to 800)  ml and 275 (125 to 800)  ml in the non-protective and lung protective ventilation groups, respectively (P = 0.47). Fourteen (35.0%) and eight (21.5%) patients were transfused in the non-protective and lung protective groups, respectively (P = 0.17), without a statistically significant difference in the median (interquartile range) number of red blood cells units transfused [2.5 (2 to 4) units and 3 (2 to 6) units in the two groups, respectively; P = 0.54]. CONCLUSION: During hepatic surgery, mechanical ventilation using PEEP within a multi-faceted lung protective strategy was not associated with increased bleeding compared with non-protective ventilation using zero PEEP. TRIAL REGISTRATION: The current study was not registered. The original Intraoperative Protective Ventilation study was registered on clinicaltrials.gov; number NCT01282996.

Sedative premedication before surgery--A multicentre randomized study versus placebo.

OBJECTIVE: Anxiolytic premedication before non-ambulatory surgery in adult patients may have become of less importance in an era of better preoperative patient information. Moreover, an oral hypnotic given the night before surgery may be as efficient as an anxiolytic for relieving patient anxiety. These two strategies were compared for superiority to a placebo and to each other for non-inferiority. STUDY DESIGN: Double-blind, randomized, multicentre study versus placebo. Eight hospitals in France. June 2011 to February 2013. PATIENTS: Non-ambulatory consecutive surgical patients undergoing general surgery. METHODS AND INTERVENTIONS: Patients received either zopiclone 7.5mg the night before surgery (n=204), or alprazolam 0.5mg the morning of surgery (n=206) and controls received placebo (n=68). Demographic data, preoperative anxiety, fear of surgery and anaesthesia, and mood were assessed the day before surgery using a visual analogue scale, the Spielberger scale and the APAIS scale. In the operating room, anxiety and comfort were assessed in addition to physiological data. RESULTS: Preoperative data did not differ between groups. In the operating room, anxiety and comfort were moderate and did not differ significantly between groups on a 1-10 scale (median [25-75 percentile]): zopiclone: 2 [1-4] and 2.5 [1-5]; alprazolam: 2 [1,4] and 2 [1-5]; placebo: 3 [1-5] and 3 [1-5]. The patients who were more anxious preoperatively remained so in the operating room, irrespective of the treatment received (r=0.31, p<0.001). A placebo effect was observed in 38% of patients in the corresponding group. Patients receiving zopiclone reported a significantly better sleep the night before surgery compared to other groups (median: 2 vs. 1, p<0.001). CONCLUSIONS: Premedication in non-ambulatory surgery is no more effective than a placebo, owing to the very moderate level of anxiety experienced by patients.

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.

Pneumonia prevention to decrease mortality in intensive care unit: a systematic review and meta-analysis.

BACKGROUND: To determine the strategies of prevention of hospital-acquired pneumonia that reduce mortality in intensive care unit (ICU). METHODS: We followed PRISMA (Preferred Reported Items for Systemic Reviews and Meta-Analyses) guidelines. We searched MEDLINE and the Cochrane Controlled Trials Register (through 10 June 2014) as well as reference lists of articles. We included all randomized controlled trials conducted in critically ill adult patients hospitalized in ICUs and evaluating digestive prophylactic methods (selective digestive decontamination [SDD], acidification of gastric content, early enteral feeding, prevention of microinhalation); circuit prophylactic methods (closed suctioning systems, early tracheotomy, aerosolized antibiotics, humidification, lung secretion drainage, silver-coated endotracheal tubes) or oropharyngeal prophylactic methods (selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, tracheal cuff monitoring). One reviewer extracted data that were checked by 3 others. The primary outcome was the mortality rate in the ICU. RESULTS: We identified 157 randomized trials to pool in a meta-analysis. The primary outcome was available in 145 studies (n = 37 156). The risk ratio (RR) for death was 0.95 (95% confidence interval [CI], .92-.99; P = .02) in the intervention groups. In subgroup analysis, only SDD significantly decreased mortality compared with control (n = 10 227; RR, 0.84 [95% CI, .76-.92; P < .001]). The RR for in-ICU death was 0.78 (95% CI, .69-.89; P < .001; I(2) = 33%) in trials investigating SDD with systemic antimicrobial therapy and 1.00 (.84-1.21; P = .96; I(2) = 0%) without systemic antimicrobial therapy. CONCLUSIONS: Selective digestive decontamination with systemic antimicrobial therapy reduced mortality and should be considered in critically ill patients at high risk for death.

Bleeding complications in patients with coronary stents during non-cardiac surgery.

INTRODUCTION: Patients with coronary stents often undergo non-cardiac invasive procedures. These are often associated with thrombotic and/or hemorrhagic complications. The type of procedure, perioperative antiplatelet therapy, and other patient-related factors influence the risk of postoperative haemorrhage. Our objective was to analyze the postoperative risk factors for hemorrhagic complications and to determine the impact of antiplatelet and anticoagulant therapy strategies on postoperative bleeding risk in patients with coronary stents undergoing non-cardiac surgery. PATIENTS AND METHODS: Prospective, multicentre observational cohort study of 1134 consecutive patients with coronary stents undergoing non-cardiac surgery between April 2007 and April 2009. The primary outcome measure was the occurrence of an hemorrhagic complication during the first 30days following the surgery or intervention. RESULTS: Among the 1134 patients evaluated, 108 (9.5%) experienced a postoperative hemorrhagic complication (with a median time to occurrence of 5.3days). These complications were considered major, involved the operative site, and required reoperation in 92 (85.2%), 92 (85.2%), and 20 (18.5%) of patients, respectively. Mortality in patients with a haemorrhagic complication was 12% (n=13). Independent postoperative factors associated with haemorrhagic complications were identified as a high and intermediate bleeding risk procedure and the use and dose of anticoagulants. When interrupted before the procedure, resumption of antiplatelet treatment was delayed in patients developing early postoperative hemorrhagic complications. CONCLUSION: Patients with coronary stents who undergo surgery are at high risk for hemorrhagic complications.

Compliance with guidelines for the perioperative management of vitamin K antagonists.

INTRODUCTION: Perioperative vitamin K antagonist management is an issue of concern in many countries. The availability of best practice guidelines meets health professionals' needs, but compliance is uncertain and should be assessed. MATERIALS AND METHODS: Our aim was to assess practitioner compliance with the guidelines on perioperative VKA management issued by the French National Authority for Health through a national register set up in partnership with the French College of Anaesthetists and Intensivists. Seven sections of data entry were focused on perioperative management of VKAs for elective or emergency procedures. High-risk patients were identified. Compliance with guidelines was calculated per item RESULTS: 932 charts were completed between October 2009 and December 2010. VKA therapy was interrupted in 74% (622/837) of elective procedures and bridged in 69% cases (428/622) mainly with LMWH. According to guidelines, bridging was strongly recommended in 39% high-risk patients (175/394) but 13% of these (23/175) received no bridging. Bridging was overused in 60% of low risk patients (242/406). Other compliance rates were as follows: (i) administration of therapeutic enoxaparin doses (=200IU/kg/day): only 18% of high-risk patients (18/98), (ii) INR measurement on evening prior to the procedure 65% (525/803), (iii) concomitant prothrombin complex concentrate and vitamin K administration in emergency surgery 24% (21/87), (iv) postoperative therapeutic enoxaparin doses: only 20% despite widespread prescription. The incidence rate of bleeding and thrombotic events was 7.1% and 0.96% respectively. CONCLUSIONS: These poor compliance rates with guidelines suggest that the knowledge-to-action transfer plan was inadequate and that further interventions are required.

Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia. BACKGROUND: It remains controversial whether adding epidural analgesia to general anesthesia decreases postoperative morbidity and mortality. METHODS: We searched CENTRAL, EMBASE, PubMed, CINAHL, and BIOSIS till July 2012. We included randomized controlled trials comparing epidural analgesia (with local anesthetics, lasting for ≥ 24 hours postoperatively) with systemic analgesia in adults having surgery under general anesthesia, and reporting on mortality or any morbidity endpoint. RESULTS: A total of 125 trials (9044 patients, 4525 received epidural analgesia) were eligible. In 10 trials (2201 patients; 87 deaths), reporting on mortality as a primary or secondary endpoint, the risk of death was decreased with epidural analgesia (3.1% vs 4.9%; odds ratio, 0.60; 95% confidence interval, 0.39-0.93). Epidural analgesia significantly decreased the risk of atrial fibrillation, supraventricular tachycardia, deep vein thrombosis, respiratory depression, atelectasis, pneumonia, ileus, and postoperative nausea and vomiting, and also improved recovery of bowel function, but significantly increased the risk of arterial hypotension, pruritus, urinary retention, and motor blockade. Technical failures occurred in 6.1% of patients. CONCLUSIONS: In adults having surgery under general anesthesia, concomitant epidural analgesia reduces postoperative mortality and improves a multitude of cardiovascular, respiratory, and gastrointestinal morbidity endpoints compared with patients receiving systemic analgesia. Because adverse effects and technical failures cannot be ruled out, individual risk-benefit analyses and professional care are recommended.

Lobectomy and postoperative thromboprophylaxis with enoxaparin improve blood hypercoagulability in patients with localized primary lung adenocarcinoma.

BACKGROUND: Patients with lung adenocarcinoma undergoing surgery are in high risk for VTE and receive routine post-operative thromboprophylaxis with LWMH. AIM: We investigated markers of hypercoagulability in patients with primary localized adenocarcinoma and the modifications induced by lobectomy and postoperative administration of enoxaparin. MATERIALS AND METHODS: Patients suffering from localised primary lung adenocarcinoma (n=15) scheduled for lobectomy were studied. The control group consisted of 15 healthy age and sex-matched individuals. Blood was collected before anaesthesia induction and after surgery, at several intervals until the 7th post-operative day. Samples were assessed for thrombin generation, phosphatidylserin expressing platelet derived microparticles expressing (Pd-MP/PS(+)), tissue factor activity (TFa), FVIIa and TFPI levels, procoagulant phospholipid dependent clotting time and anti-Xa activity. RESULTS: At baseline, patients showed increased thrombin generation and Pd-MP/PS(+). After lobectomy thrombin generation significantly decreased. Administration of enoxaparin attenuated thrombin generation. In about 50% of samples collected post-operatively an increase of thrombin generation occurred despite the presence of the expected anti-Xa activity in plasma. At the 7th post-operative day, 3 out of 15 patients showed a significant increase of thrombin generation. CONCLUSION: In patients with localized lung adenocarcinoma, hypercoagulability is characterized by high thrombin generation and increased concentration of Pd-MP/PS(+). Tumor mass resection is related with attenuation of thrombin generation, which is inhibited by postoperative thromboprophylaxis with enoxaparin. The response to enoxaparin is not predicted by the concentration of the anti-Xa activity in plasma. The assessment of thrombin generation during prophylaxis with enoxaparin allows to identify patients with high residual plasma hypercoagulability.

A trial of intraoperative low-tidal-volume ventilation in abdominal surgery.

BACKGROUND: Lung-protective ventilation with the use of low tidal volumes and positive end-expiratory pressure is considered best practice in the care of many critically ill patients. However, its role in anesthetized patients undergoing major surgery is not known. METHODS: In this multicenter, double-blind, parallel-group trial, we randomly assigned 400 adults at intermediate to high risk of pulmonary complications after major abdominal surgery to either nonprotective mechanical ventilation or a strategy of lung-protective ventilation. The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within the first 7 days after surgery. RESULTS: The two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval [CI], 0.24 to 0.68; P=0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% CI, 0.14 to 0.61; P=0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, -2.45 days; 95% CI, -4.17 to -0.72; P=0.006). CONCLUSIONS: As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.).