PROSPECT guideline for total hip arthroplasty: a systematic review and procedure-specific postoperative pain management recommendations.

The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine.

PROSPECT guideline for tonsillectomy: systematic review and procedure-specific postoperative pain management recommendations.

Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure-specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta-analysis guidelines with procedure-specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre-operative and intra-operative interventions that improved postoperative pain were paracetamol; non-steroidal anti-inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra-operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first-line analgesics are contra-indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

Multicentre, prospective, double-blind, randomised controlled clinical trial comparing different non-opioid analgesic combinations with morphine for postoperative analgesia: the OCTOPUS study.

BACKGROUND: Head-to-head comparisons of combinations of more than one non-opioid analgesic (NOA) with morphine alone, for postoperative analgesia, are lacking. The objective of this multicentre, randomised, double-blind controlled trial was to compare the morphine-sparing effects of different combinations of three NOAs-paracetamol (P), nefopam (N), and ketoprofen (K)-for postoperative analgesia. METHODS: Patients from 10 hospitals were randomised to one of eight groups: control (C) received saline as placebo, P, N, K, PN, PK, NK, and PNK. Treatments were given intravenously four times a day during the first 48 h after surgery, and morphine patient-controlled analgesia was used as rescue analgesia. The outcome measures were morphine consumption, pain scores, and morphine-related side-effects evaluated 24 and 48 h after surgery. RESULTS: Two hundred and thirty-seven patients undergoing a major surgical procedure were included between July 2013 and November 2016. Despite a failure to reach a calculated sample size, 24 h morphine consumption [median (inter-quartile range)] was significantly reduced in the PNK group [5 (1-11) mg] compared with either the C group [27 (11-42) mg; P<0.05] or the N group [21 (12-29) mg; P<0.05]. Results were similar 48 h after surgery. Patients experienced less pain in the PNK group compared with the C, N, and P groups. No difference was observed in the incidence of morphine-related side-effects. CONCLUSIONS: Combining three NOAs with morphine allows a significant morphine sparing for 48 h after surgery associated with superior analgesia the first 24 h when compared with morphine alone. CLINICAL TRIAL REGISTRATION: EudraCT: 2012-004219-30; NCT01882530.

Overuse of preoperative laboratory coagulation testing and ABO blood typing: a French national study.

Background: Following publication of guidelines on routine preoperative tests, the French Society of Anaesthesiology and Intensive Care (SFAR), in association with French national public health insurance, conducted a survey to evaluate adherence to guidelines and the economic consequences. Methods: Using the French Hospital Discharge Database and National Health Insurance Information system, tests performed during the 30 days before surgery were analysed for two situations: (1) standard laboratory coagulation tests and ABO blood typing in children able to walk and scheduled for tonsillectomy/adenoidectomy; and (2) ABO blood typing in adults before laparoscopic cholecystectomy, thyroidectomy, lumbar discectomy or breast surgery. Guidelines do not recommend any preoperative tests in these settings. Results: Between 2013 and 2015, a coagulation test was performed in 49% of the 241 017 children who underwent tonsillectomy and 39% of the 133 790 children who underwent adenoidectomy. A similar pattern was observed for ABO blood typing although re-operation rates for bleeding on the first postoperative day were very low (0.12-0.31% for tonsillectomy and 0.01-0.02% for adenoidectomy). Between 2012 and 2015, ABO blood typing was performed in 32-45% of the 1 114 082 patients who underwent one of the four selected procedures. The transfusion rate was very low (0.02-0.31%). The mean cost for the four procedures over the 4 yr period was €5 310 000 (sd €325 000). Conclusions: Standard laboratory coagulation tests and ABO blood typing are still routinely prescribed before surgery and anaesthesia despite current guidelines. This over-prescription represents a high and unnecessary cost, and should therefore be addressed.

Non-opioid analgesics in adults after major surgery: systematic review with network meta-analysis of randomized trials.

BACKGROUND: Morphine, and analgesics other than morphine (AOM), are commonly used to treat postoperative pain after major surgery. However, which AOM provides the best efficacy-safety profile remains unclear. METHODS: Randomized trials of any AOM alone or any combination of AOM compared with placebo or another AOM in adults undergoing major surgery and receiving morphine patient-controlled analgesia were included in a network meta-analysis. The outcomes were morphine consumption, pain, incidence of nausea, vomiting at 24 h and severe adverse effects. RESULTS: 135 trials (13,287 patients) assessing 14 AOM alone or in combination were included. For all outcomes, comparisons with placebo were over-represented. Few trials assessed combinations of two AOM and none the combination of three or more. Network meta-analysis found morphine consumption reduction was greatest with the combination of two AOM (acetaminophen + nefopam, acetaminophen + NSAID, and tramadol + metamizol): -23.9 (95% CI -40;-7.7), -22.8 (-31.5;-14) and -19.8 (35.4;-4.2) mg per 24 h, respectively. For AOM used alone, morphine consumption reduction was greatest with α-2 agonists, NSAIDs, and COX-2 inhibitors. When considering the risk of nausea, NSAIDs, corticosteroids and α-2 agonists used alone were the most efficacious (OR 0.7 [95% CI: 0.6-0.8], 0.36 [0.18-0.79], 0.41 [0.15-.64], respectively). The paucity of severe adverse effects data did not allow assessment of efficacy-safety balance. CONCLUSIONS: A combination of aetaminophen with either an NSAID or nefopam was superior to most AOM used alone, in reducing morphine consumption. Efficacy was best with three AOM used alone (α-2 agonists, NSAIDs and COX-2 inhibitors) and least with tramadol and acetaminophen. There is insufficient trial data reporting adverse events. CLINICAL TRIAL REGISTRATION: PROSPERO: CRD42013003912.

What are the therapeutic alternatives to dextropropoxyphene in France? A prescribers' survey.

About a year after dextropropoxyphene (DXP) withdrawal from the French market, we conducted a survey among members of the French Society of Anesthesia & Intensive Care Medicine (Sfar) and of the French Society of the Study and Treatment of Pain (SFETD) to identify the indications for which this WHO level II analgesic had been prescribed, the prescriber's feedback following withdrawal, and the substitutive analgesics prescribed. DXP had been prescribed by more than 75% of the 430 anaesthesiologists and 230 pain specialists interviewed, mainly for acute and chronic non-cancer pain of moderate intensity. While two thirds of pain specialists were not satisfied with DXP withdrawal, this decision did not affect the majority of anaesthesiologists. In both groups, the main substitutive analgesic was tramadol combined with acetaminophen, while only 24% of prescribers considered acetaminophen alone as a substitute.

Peri-operative pain and its consequences.

Recent advances in the management of peri-operative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain pre-operatively, pre-operative opioid use, and the intensity of post-operative pain. Ideal management of peri-operative pain in 2015 aims to optimize post-operative pain management, to detect the risk of pain chronicity begins pre-operatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in post-operative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer [1], and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intra-operative and post-operative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications.

Colonic anastomoses and non-steroidal anti-inflammatory drugs.

Nonsteroidal anti-inflammatory drugs (NSAID) play an important role in the treatment of post-operative pain, particularly in the context of enhanced recovery after colorectal surgery. Several recent articles have suggested that NSAID may have a deleterious effect on colo-colic or colo-rectal anastomoses. The aim of this review is to analyze the evidence based on meta-analyses and cohort studies in the literature. A systematic review of clinical studies identified twelve studies including two meta-analyses and ten comparative cohort studies that included a large number of patients. The data in these studies are heterogeneous, often biased, and do not permit a formal recommendation based on a high level of evidence. The main conclusion of this review is that the balance of benefit vs. risk (analgesic effect/risk of anastomotic disruption) is acceptable; it appears (with a low level of evidence) that a prescription of NSAID for 48h after surgery may be recommended for elective colon surgery. Nevertheless, it is important to respect the specific contra-indications of NSAID and avoid post-operative NSAID use if there are risk factors for anastomotic leakage: advanced age, malnutrition, severe co-morbidities, intra-operative difficulties.

[Intravenous lipid emulsion and local anesthetic-induced systemic toxicity: mechanisms and limits]. / Émulsions lipidiques intraveineuses et toxicité systémique des anesthésiques locaux: mécanismes et limites.

OBJECTIVES: Intravenous lipid emulsions (ILE) are recommended today in cases of local anesthetic-induced systemic toxicity (LAST). The objectives of this review consists in describing mechanisms involved in the interaction between ILE and local anesthetic (LA) factors influencing this interaction and the limits associated with the use of ILE. DATA SOURCES: References were obtained from Pubmed data bank (http://www.ncbi.nlm.nih.gov/pubmed) using the following keywords: Intralipid(®), local anesthetic, toxicity, intravenous lipid emulsion. DATA SYNTHESIS: Effects of the association between ILE-LA are based on droplet formations as well as changes in cell metabolism involving survival cell pathway, on functional properties and on direct hemodynamic parameters. Hypoxia, acidosis and high doses of epinephrine modified the effects of ILE-LA association. CONCLUSION: Prescription of ILE is recommended by published guidelines on LAST resuscitation. ILE cannot substitute to the standard resuscitation protocol. It should be added to that protocol. Experimental studies as well as a case report registry will allow understanding further the effects induced by the ILE-LA association.

Risk factors for persistent pain after urological surgery.

OBJECTIVE: Ten to 50% of patients with post-surgical pain develop chronic pain depending on the type of surgery. The objective of this study was to assess the incidence of persistent post-surgical pain (PPSP) and to identify risk factors following urology surgery. DESIGN: Retrospective observational study. PATIENTS: Two hundred and twenty-eight patients scheduled for urology surgery. Reasons for non-inclusions: patients who underwent a procedure not defined as being associated with PPSP. METHODS: Surgical urologic procedures potentially associated with PPSP were defined. All patients who had one of these procedures during the study period received a questionnaire by mail at least 3 months after the surgery. The files of these patients were retrospectively studied. RESULTS: Eight percent of the patients had preoperative pain. PPSP, assessed approximately 6 months after the surgery, was reported by 24% of the patients. Twenty-five (36%) of them reported neuropathic pain. Patients with PPSP had significantly more preoperative pain and an increased postoperative morphine consumption. Postoperative NSAID administration led to less persistent pain. Multivariate logistic regression analysis identified two independent risk factors of developing persistent pain: preoperative pain (OR=21.6, 95% CI 6.7-69.5, P<0.0001), morphine consumption 48 hours after surgery higher than 6mg (OR=2.3, 95% CI 1.2-4.3, P=0.0118). CONCLUSION: These findings confirm the role of preoperative pain and morphine consumption in the genesis of PPSP and call for establishing clinical perioperative pathways tailored to the patient.

[Chronic pain and regional anesthesia in children]. / Douleurs chroniques et anesthésie locorégionale chez l'enfant.

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.

Cerebral oxygen saturation is improved by xenon anaesthesia during carotid clamping.

INTRODUCTION: The cerebral protective effect of xenon anesthesia could be of interest during carotid surgery. The purpose of this study was to compare the effects of xenon on cerebral oxygen saturation with those of propofol during carotid clamping. METHODS: After approval of Research Ethics Board and patient informed consent, 74 patients scheduled for carotid endarterectomy were enrolled. Patients were not randomized but were well matched by preoperative characteristics. Patients in the Xenon group were the ones scheduled for surgery in the operative theater equipped with the xenon anesthesia system. Anesthesia was started with a target control infusion of propofol and remifentanil. Patients were then divided into the control group (37 patients) with anesthesia maintained with target control infusion propofol and remifentanil and the Xenon group with anesthesia maintained with xenon (target inspired concentration of 60%) and target control infusion remifentanil. Remifentanil and xenon or propofol were stopped at the end of skin closure. RESULTS: A cerebral oxygen saturation decrease below 55% was less frequently observed in the Xenon group during carotid cross-clamping (7/37 patients vs 15/37; p=0.01). Compared with values observed before clamping, the decrease in cerebral oxygen saturation during clamping was significantly less important in the Xenon group (12±11% vs 17±14%, p=0.04). Blood pressure and heart rate were not different between groups during carotid clamping. CONCLUSIONS: This pilot study suggests that xenon anesthesia may be associated to higher cerebral oxygen saturation values when compared to propofol anesthesia during cross-clamping for carotid endarterectomy.

[The perioperative period in cancer surgery: a critical moment! Is there a role for regional anesthesia in preventing cancer recurrence?]. / La période périopératoire de chirurgie carcinologique : un moment crucial ! L'anesthésie locorégionale prévient-elle la récidive des cancers ?

Surgical treatment of cancer is usually necessary but it can paradoxically aggravate the patient outcome by increasing the risk of recurrence. Many perioperative factors have been shown to contribute to the dissemination of the tumor: surgery itself, stress, inflammation, pain, anaesthetic drugs, blood transfusion, etc. The type of anaesthesia chosen in the cancer patient could then be crucial and influence the evolution of the disease. Experimental, preclinical and retrospective studies have suggested that a regional anesthesia associated or not with a general anesthesia for carcinologic surgery might reduce the risk of cancer recurrence. This text reviews the factors promoting the recurrence of tumors after carcinologic surgery and the potential possibilities of protection associated with the type of anaesthesia chosen.

[TAP block and blocks of the abdominal wall]. / TAP bloc et blocs de la paroi abdominale.

Since the revolution of ultrasound in regional anesthesia, new techniques have arisen. The "transversus abdominis plane" block or TAP block is one of them. The benefits of a TAP block for postoperative analgesia have been shown mostly after laparotomy. Because this block seems to be technically easy, many anesthesiologists have quickly adopted it. However, the TAP block presents some technical specificities and knowledge of the anatomy is required. This article reviews the anatomy of the abdominal wall, the different blocks, the indications, the complications, and highlights the many unanswered questions left. This review proposes a new vision of the abdominal wall blocks based on a new understanding of the anatomy of the abdominal wall associated with an ultrasound technique.