Balanced Nonopioid General Anesthesia With Lidocaine Is Associated With Lower Postoperative Complications Compared With Balanced Opioid General Anesthesia With Sufentanil for Cardiac Surgery With Cardiopulmonary Bypass: A Propensity Matched Cohort Study.

BACKGROUND: There are no data on the effect of balanced nonopioid general anesthesia with lidocaine in cardiac surgery with cardiopulmonary bypass. The main study objective was to evaluate the association between nonopioid general balanced anesthesia and the postoperative complications in relation to opioid side effects. METHODS: Patients undergoing cardiac surgery with cardiopulmonary bypass between 2019 and 2021 were identified. After exclusion of patients for heart transplantation, left ventricular assistance device, and off-pump surgery, we classified patients according to an opioid general balanced anesthesia or a nonopioid balanced anesthesia with lidocaine. The primary outcome was a collapsed composite of postoperative complications that comprise respiratory failure and confusion, whereas secondary outcomes were acute renal injury, pneumoniae, death, intensive care unit (ICU), and hospital length of stay. RESULTS: We identified 859 patients exposed to opioid-balanced general anesthesia with lidocaine and 913 patients exposed to nonopioid-balanced general anesthesia. Propensity score matching yielded 772 individuals in each group with balanced baseline covariates. Two hundred thirty-six patients (30.5%) of the nonopioid-balanced general anesthesia versus 186 patients (24.1%) presented postoperative composite complications. The balanced lidocaine nonopioid general anesthesia group was associated with a lower proportion with the postoperative complication composite outcome OR, 0.72 (95% CI, 0.58-0.92; P = .027). The number of patients with acute renal injury, death, and hospital length of stay did not differ between the 2 groups. CONCLUSIONS: A balanced nonopioid general anesthesia protocol with lidocaine was associated with lower odds of postoperative complication composite outcome based on respiratory failure and confusion.

Levosimendan in venoarterial ECMO weaning. Rational and design of a randomized double blind multicentre trial.

AIMS: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly being used in circulatory failure. The main indications are cardiogenic shock, post-cardiotomy cardiac failure, and refractory cardiac arrest. However, VA-ECMO weaning is particularly challenging, and weaning failure is reported to be as high as 50%, with increased related mortality. Levosimendan is a novel long acting effect inodilator used in cardiogenic shock and terminal heart failure decompensation. Levosimendan use in VA-ECMO patients seems to reduce weaning failure regardless of the initial aetiology and to reduce mortality when administrated early after VA-ECMO initiation. However, studies are limited to retrospective analyses and reported case series. The aim of the WEANILEVO trial is to evaluate whether administration of levosimendan before VA-ECMO weaning is associated with a reduced rates of weaning failure and recourse to other temporary circulatory support. METHODS AND RESULTS: WEANILEVO is a randomized, prospective, multicentre, double-blind, parallel-group, controlled trial. One hundred eighty patients will be enrolled if they had acute circulatory heart failure treated with VA-ECMO and for whom weaning is expected within 48 h. The study drugs are either levosimendan (0.2 µg/kg/min for 24 h) or a placebo. The primary endpoint of the trial is the absence of VA-ECMO weaning, recourse to another VA-ECMO, or other temporary circulatory assistance or death within 7 days of VA-ECMO weaning. CONCLUSIONS: Levosimendan use in VA-ECMO appears to be beneficial for reducing weaning failure and mortality. The results of WEANILEVO should significantly influence decisions regarding the use of levosimendan for VA-ECMO weaning.

Pupillometry pain index decreases intraoperative sufentanyl administration in cardiac surgery: a prospective randomized study.

Pupillometry has proven effective for the monitoring of intraoperative analgesia in non-cardiac surgery. We performed a prospective randomized study to evaluate the impact of an analgesia-guided pupillometry algorithm on the consumption of sufentanyl during cardiac surgery. Fifty patients were included prior to surgery. General anesthesia was standardized with propofol and target-controlled infusions of sufentanyl. The standard group consisted of sufentanyl target infusion left to the discretion of the anesthesiologist. The intervention group consisted of sufentanyl target infusion based on the pupillary pain index. The primary outcome was the total intraoperative sufentanyl dose. The total dose of sufentanyl was lower in the intervention group than in the control group and (55.8 µg [39.7-95.2] vs 83.9 µg [64.1-107.0], p = 0.04). During the postoperative course, the cumulative doses of morphine (mg) were not significantly different between groups (23 mg [15-53] vs 24 mg [17-46]; p = 0.95). We found no significant differences in chronic pain at 3 months between the 2 groups (0 (0%) vs 2 (9.5%) p = 0.49). Overall, the algorithm based on the pupillometry pain index decreased the dose of sufentanyl infused during cardiac surgery.Clinical trial number: NCT03864016.

Anaesthesia and ICU sedation with sevoflurane do not reduce myocardial injury in patients undergoing cardiac surgery: A randomized prospective study.

BACKGROUND: To evaluate the effect of anaesthesia and ICU sedation with sevoflurane to protect the myocardium against ischemia-reperfusion injury associated to cardiac surgery assessed by troponin release. METHODS: We performed a prospective, open-label, randomized study in cardiac surgery with cardiopulmonary bypass. Patients were randomized to an algorithm-based intervention group and a control group. The main outcome was the perioperative kinetic of cardiac troponin I (cTnI). The secondary outcomes included composite endpoint, GDF-15 (macrophage inhibitory cytokine-1) value, arterial lactate levels, and the length of stay (LOS) in the ICU. RESULTS: Of 82 included patients, 81 were analyzed on an intention-to-treat basis (intervention group: n = 42; control group: n = 39). On inclusion, the intervention and control groups did not differ significantly in terms of demographic and surgical data. The postoperative kinetics of cTnI did not differ significantly between groups: the mean difference was 0.44 ±â€Š1.09 µg/ml, P = .69. Incidence of composite endpoint and GDF-15 values were higher in the sevoflurane group than in propofol group. The intervention and control groups did not differ significantly in terms of ICU stay and hospital stay. CONCLUSION: The use of an anaesthesia and ICU sedation with sevoflurane was not associated with a lower incidence of myocardial injury assessed by cTnI. Sevoflurane administration was associated with higher prevalence of acute renal failure and higher GDF-15 values.

Preoperative hypnosis for pain management after arthroscopic repair of anterior cruciate ligament.

BACKGROUND: The practice of hypnoanalgesia in orthopedics is rare and the literature is poor. AIM: The purpose of this pilot study was to verify the efficacy of hypnosis for the management of postoperative analgesia after arthroscopic repair of anterior cruciate ligament. METHODS: This was a prospective clinical trial over a period of 6 months (March - August 2015) including 25 patients scheduled for arthroscopic repair of anterior cruciate ligament under spinal anesthesia. All these patients had preoperative hypnosis in addition to the standard multimodal analgesia protocol (group H) and were compared to historical group (group S) who received only a standard multimodal analgesia protocol. RESULTS: Pain scores were significantly lower for the hypnosis group during the first 48 hours postoperatively (p = 0,006). The total dose of morphine at 48 hours was: 13,6 mg (95% CI [4,58; 22,62]) in the group H and 10,2 mg (95% CI [1,64 ; 18,76]) in group S with no statistically significant difference (p = 0,178) Conclusion: Results of this pilot study in orthopedic surgery suggested that hypnosis reduced postoperative pain scores as demonstrated in other surgeries.

Adductor canal block: Effect of volume of injectate on sciatic extension.

CONTEXT: Spread of local anesthetic within adductor canal to peroneal and tibial nerves is described in literature. This spread could be volume-dependent. AIMS: In this study, we compared the diffusion of two volumes of 0.375% ropivacaine to popliteal fossa. SETTINGS AND DESIGN: This was a prospective, randomized controlled, single-blind study conducted in Kassab Orthopaedic Institute of Tunis for 1 year (2018). MATERIALS AND METHODS: A total of 42 patients, American Society of Anesthesiologists I/II scheduled for knee arthroscopy under spinal anesthesia scheduled to receive adductor canal block, were randomized into two groups: group N received 20 mL of ropivacaine 0.375% and group H received 40 mL. We evaluated sensory motor blocks of both peroneal and tibial nerves at 30 and 60 min. STATISTICAL ANALYSIS USED: Chi-square or Fisher's exact test was used to compare the number and percentage. P <0.05 was significant. RESULTS: At 60 min, complete sensory block of the peroneal nerve was obtained for 16 patients in group H versus 15 patients in group N with no statistically significant difference (P = 0.60). The difference was also not significant (P = 0.27) for the tibial nerve: 14 patients for group H versus 16 for group N. Motor blockade was rare in the two nerve territories. CONCLUSION: Spread of 0.375% ropivacaine to popliteal fossa resulted in high rate of complete sensory blockade of both peroneal and tibial nerves. Diffusion of local anesthetic was not volume-dependent.

Perioperative morbidity in total knee arthroplasty.

INTRODUCTION: As the life expectancy and weight of patients are increasing, more old and obese patients are undergoing total knee arthroplasty (TKA). TKA may lead to several perioperative complications. These include anesthesia-related risks, exacerbation of comorbid medical issues and complications of surgical procedure. We have no studies reporting medical complications following TKA among our population. This study aimed to evaluate perioperative complications of TKA and to identify the related risk factors. METHODS: It was a monocentric retrospective including 410 observations in the local TKA registry. Data of patients operated for primary unilateral TKA during the period from January 2014 to December 2017 were reviewed. All patients had standardized protocols of anesthesia and post operative care for three days following surgery. Multivariate logistic regression was used to identify the predicting factors for complications. RESULTS: Incidence of perioperative complications was 37.1%. The most frequent were per operative hypotension (14.1%) and postoperative desaturation (21.7%, including pulmonary embolism in 2.4%). Multivariate logistic regression analysis identified: age ≥ 65 years (OR=1.9; p=0.006), respiratory diseases (OR=1.8; p=0.042) and general anesthesia (OR=2.8; p=0.009) as significant risk factors for any complications. Loss of autonomy (OR=4.8; p <0.001) and general anesthesia (OR=2.6; p=0.03) were significant risk factors for hypotension. Age ≥ 65 years (OR=2.6;p<0.001), female gender (OR=4.3;p=0.006) and respiratory diseases(OR=1.9;p=0.02) were associated with postoperative desaturation. CONCLUSION: This study highlighted hemodynamic and respiratory complications as the most common early complications in TKA. Age ≥ 65years, general anesthesia and respiratory diseases were significant risk factors.

Effect of opioid-free anaesthesia on post-operative period in cardiac surgery: a retrospective matched case-control study.

BACKGROUND: No study has been conducted to demonstrate the feasibility of an opioid-free anesthesia (OFA) protocol in cardiac surgery to improve patient care. The aim of the present study was to evaluate the effect of OFA on post-operative morphine consumption and the post-operative course. METHODS: After retrospectively registering to clinicaltrial.gov (NCT03816592), we performed a retrospective matched cohort study (1:1) on cardiac surgery patients with cardiopulmonary bypass between 2018 and 2019. Patients were divided into two groups: OFA (lidocaine, dexamethasone and ketamine) or opioid anaesthesia (OA) (sufentanil). The main outcome was the total postoperative morphine consumption in the 48 h after surgery. Secondary outcomes were rescue analgesic use, a major adverse event composite endpoint, and ICU and hospital length of stay (LOS). RESULTS: One hundred ten patients were matched (OFA: n = 55; OA: n = 55). On inclusion, demographic and surgical data for the OFA and OA groups were comparable. The total morphine consumption was higher in the OA group than in the OFA group (15 (6-34) vs 5 mg (2-18), p = 0.001). The pain score during the first 48 post-operative hours did not differ between the two groups. Creatinine values did not differ on the first post-operative day (80 (IQR: 66-115) vs 77 mmol/l (IQR: 69-95), p = 0.284). Incidence of the composite endpoint was lower in the OFA group (25 patients (43%) vs 38 patients (68%), p = 0.021). The time to extubation and the ICU stays were shorter in the OFA group (3 (1-5) vs 5 (3-6) hours, p = 0.001 and 2 (1-3) vs 3 (2-5) days, p = 0.037). CONCLUSION: The use of OFA was associated with lower morphine consumption. OFA might be associated with shorter intubation time and ICU stays. Further randomized studies are needed to confirm these results. TRIAL REGISTRATION: This study was retrospectively registered to ct2 (identifier: NCT03816592 ) on January 25, 2019.