Continuous Ropivacaine Peroneal Nerve Infiltration for Fibula Free Flap in Cervicofacial Cancer Surgery: A Randomized Controlled Study.

Introduction: Pain after cervicofacial cancer surgery with free flap reconstruction is both underestimated and undertreated. There is a rational for regional anesthesia at the flap harvest site, but few studies describe it. We assessed the influence of common peroneal nerve infiltration on pain and opioid consumption in patients having oropharyngeal cancer surgery with fibular free flap mandibular reconstruction. Methods: After institutional review board (IRB) approval and written informed consent, fifty-six patients were randomly allocated to perineural catheter with ropivacaine infiltration (ROPI) or systemic analgesia (CONTROL). In the ROPI group, an epidural catheter was placed by the surgeon before closure, and ropivacaine 0.2% 15 mL, followed by 4 mL/h during 48 h, was administered. The primary outcomes were pain scores and morphine consumption during the 48 h postoperative period. We also measured ropivacaine concentration at the end of infusion. Finally, we retrospectively assessed long-term pain up to 10 years using electronic medical charts. Results: Perineural infiltration of ropivacaine significantly reduced pain scores at the harvest site only at day 1, and did not influence overall postoperative opioid consumption. Ropivacaine assay showed a potentially toxic concentration in 50% of patients. Chronic pain was detected at the harvest site in only one patient (ROPI group), and was located in the cervical area in the case of disease progression. Discussion: Although the catheter was visually positioned by the surgeon, continuous ropivacaine infiltration of the common peroneal nerve did not significantly reduce postoperative pain, but induced a blood concentration close to the toxic threshold at day 2. Further studies considering other infiltration locations or other dosing schemes should be tested in this context, both to improve efficacy and reduce potential toxicity.

Adding Low-Dose Propofol to Limit Anxiety during Target-Controlled Infusion of Remifentanil for Gastrointestinal Endoscopy: Respiratory Issues and Safety Recommendations.

Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients' characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses.

Paraspinous Quadratus Lumborum Block: A New Analgesic Option for a Thigh Sarcoma Resection With Reconstruction-A Case Report.

Efficient pain management is essential for postoperative rehabilitation in patients undergoing a tumor resection with an immediate reconstructive surgery. Ultrasound-guided quadratus lumborum block has been described for abdominal or hip surgery, but not for concomitant surgery in the abdomen and the thigh. The paraspinous transmuscular approach has easy landmarks to perform this block. We present a case of a patient undergoing a resection of a sarcoma in the lower limb with an immediate reconstruction with a pedicled vertical designed deep inferior epigastric perforator flap, in whom a successful paraspinous transmuscular quadratus lumborum block for postoperative analgesia was performed.

Efficacy of target controlled infusion of remifentanil with spontaneous ventilation for procedural sedation and analgesia (Remi TCI PSA): A double center prospective observational study.

OBJECTIVE: Remifentanil, a rapid onset rapid offset synthetic opioid and potent analgesic, is often used for procedural conscious sedation in spontaneous ventilation, especially when delivered in target controlled infusion (TCI), which allows precise titration. We assessed efficacy, tolerance, and adverse events related with the use of remifentanil TCI during various procedures. DESIGN: Prospective, observational. SETTING: Two teaching hospitals. PATIENTS: We enrolled 434 patients undergoing procedures suitable for conscious sedation. INTERVENTIONS: The following procedures considered suitable were included: interventional radiology, gastrointestinal (GI) endoscopy, interventional cardiology, and peripheral dermatology. Sedation options were determined during the preoperative anesthesia assessment. MAIN OUTCOME MEASURES: Demographics were recorded as well as success rate, remifentanil dosage, pain scores, respiratory or cardiovascular events, and patient and operator satisfaction. RESULTS: The procedure was successful in 429 patients (99 percent), canceled in four patients because of agitation, apnea, desaturation, and converted to general anesthesia in two for major pain. The maximal remifentanil target was around 2-3 ng/ml for most procedures, but it was 3-5 ng/ml for GI endoscopy and urology. A total of 172 patients (40 percent) had bradypnea < 8 min-1, but only 26 (6 percent) had hypoxemia < 90 percent. Eighteen patients (4 percent) required mandibular luxation, and twelve needed face mask ventilation. There were no major cardiovascular adverse events. CONCLUSIONS: Remifentanil TCI is a suitable protocol for procedural sedation, but respiratory depression is a permanent concern. This risk requires equipped environment and competent medical personnel on hand to adjust the target before hypoxemia occurs. Respiratory rate monitoring, based on capnography or thoracic impedance is of a great help in anticipating this threat.

Hypnosedation for endocavitary uterovaginal applications: A pilot study.

PURPOSE: Implantations for uterovaginal brachytherapy are usually performed under general or spinal anesthesia, which are not without risk. As it is a rather short procedure and since postoperative pain is minimal, hypnosedation was proposed to selected patients requiring endocavitary applications as part of their routine treatment. METHODS AND MATERIALS: Consecutive patients requiring intracavitary uterovaginal brachytherapy from January to October 2019 were included if they accepted the procedure. A premedication was systematically administered. Hypnosedation was based on an Ericksonian technique. The procedure was immediately interrupted if the patient requested it, in cases of extreme anxiety or pain. Procedure was in that case rescheduled with a "classical" anesthesia technique. RESULTS: A total of 20 patients were included. Four patients had to be converted toward a general anesthesia: one because of a fibroma on the probe's way and three young patients with a very anteverted/retroverted uterus that was painful at every mobilization. Mean and maximum pain scores during implant were 2.9/10 and 5.1/10, respectively. The most painful maneuver was cervical dilation for 45% of the patients, followed by mold insertion in 40% of cases. About 85% of the patients declared that hypnosis helped them relax; 90% of the patients would recommend the technique. No procedure-related complication occurred. CONCLUSION: With a 70% success rate (correct implant with mean pain and anxiety scores < 5), one can conclude that uterovaginal brachytherapy implantation under hypnosedation is feasible and received a high satisfaction rate from the patients. This technique may reduce overall treatment time in a context of difficult access to the OR and to anesthesiologists, while reducing anesthetic drugs resort and postoperative nausea.

Perioperative management of patients with coronary artery disease undergoing non-cardiac surgery: Summary from the French Society of Anaesthesia and Intensive Care Medicine 2017 convention.

This review summarises the specific stakes of preoperative, intraoperative, and postoperative periods of patients with coronary artery disease undergoing non-cardiac surgery. All practitioners involved in the perioperative management of such high cardiac risk patients should be aware of the modern concepts expected to decrease major adverse cardiac events and improve short- and long-term outcomes. A multidisciplinary approach via a functional heart team including anaesthesiologists, cardiologists and surgeons must be encouraged. Rational and algorithm-guided management of those patients should be known and implemented from preoperative to postoperative period.

Comparison of the TOF-Scan™ acceleromyograph to TOF-Watch SX™: Influence of calibration.

INTRODUCTION: Quantitative neuromuscular monitoring is now widely recommended during anesthesia using neuromuscular blocking agents to prevent postoperative residual paralysis and its related complications. We compared the TOF-Watch SX™ accelerometer requiring initial calibration to the TOF-Scan™, a new accelerometer with a preset stimulation intensity of 50mA not necessitating calibration. STUDY DESIGN: This pilot, prospective, observational study included adults undergoing general anesthesia with endotracheal intubation and muscle relaxation, having both arms free during surgery. Accelerometers were set up randomly on each arm. Anesthesia was started with remifentanil and propofol before an intubation dose of atracurium or rocuronium. Train of four stimulation was performed every 15s. Differences between measures were tested using Student's t-test and agreement assessed by Bland and Altman analysis. RESULTS: Thirty-two patients were included. During onset, a mean bias of -26seconds with a limit of agreement from -172 to +119seconds was observed between TOF-Watch SX™ and TOF-Scan™ to obtain 0 response to TOF. During recovery, TOF-Scan™ showed a significantly later recovery from 1 response to T4/T1>10%, but a bias of 0minute and limits of agreement from -4 to +4minutes for T4/T1>90% (NS). CONCLUSION: These results suggest a poor agreement between the calibrated TOF-Watch SX™ and the fix intensity TOF-Scan™ for onset and early recovery of relaxation (i.e. deep neuromuscular blockade) but a good agreement for recovery to TOF 90%. Data are not interchangeable between the devices, but both can be useful to detect residual paralysis.

Pharmacokinetic-pharmacodynamic relationship of anesthetic drugs: from modeling to clinical use.

Anesthesia is a combination of unconsciousness, amnesia, and analgesia, expressed in sleeping patients by limited reaction to noxious stimulations. It is achieved by several classes of drugs, acting mainly on central nervous system. Compared to other therapeutic families, the anesthetic drugs, administered by intravenous or pulmonary route, are quickly distributed in the blood and induce in a few minutes effects that are fully reversible within minutes or hours. These effects change in parallel with the concentration of the drug, and the concentration time course of the drug follows with a reasonable precision mathematical models based on the Fick principle. Therefore, understanding concentration time course allows adjusting the dosing delivery scheme in order to control the effects.   The purpose of this short review is to describe the basis of pharmacokinetics and modeling, the concentration-effects relationship, and drug interactions modeling to offer to anesthesiologists and non-anesthesiologists an overview of the rules to follow to optimize anesthetic drug delivery.

Remifentanil target-controlled infusion: a safe rescue protocol for unexpected severe postoperative pain.

Three cases are reported here in which remifentanil administered as a target-controlled infusion (TCI) was used in Post Anesthesia Care Unit as a fast rescue treatment for acute and unexpected severe postoperative pain, allowing subsequent clinical evaluation and rational titration of analgesia with longer acting opioids. It illustrates the efficacy of this technique to titrate and compensate for variability in opioid requirements. However, its safety requires full knowledge of TCI technique, continuous monitoring of respiratory function, and assisted ventilation equipment immediately available.

Flexible fiberoptic bronchoscopy and remifentanil target-controlled infusion in ICU: a preliminary study.

PURPOSE: Flexible fiberoptic bronchoscopy (FFB) is a major diagnostic tool commonly used in intensive care unit (ICU). However, it generates discomfort and pain and can worsen respiratory and/or hemodynamic condition of critically ill patients. Remifentanil is an ultrashort-acting opioid drug that has been shown to provide effective sedation for painful procedures in spontaneous breathing patients. The aim of this study is to evaluate the safety and efficacy of sedation with remifentanil target-controlled infusion (Remi-TCI) in patients with spontaneous ventilation undergoing FFB in ICU. METHODS: Monocentric prospective study. All patients received Remi-TCI with initial effect-site target concentration of 2 ng/mL, progressively titrated according to their comfort and sedation. Respiratory and hemodynamic parameters were assessed before, during, and after the procedure, as well as comfort, level of sedation, FFB conditions, and recovery patterns. Global Remi-TCI data and potential complications of the procedure were also recorded. RESULTS: Fourteen patients were included. FFB was successful in all patients with good conditions (sedation, global comfort, and cough). No severe hemodynamic or respiratory complications occurred during procedure. Maximum target concentration and total dose of remifentanil were 2.5 ng/mL (2-4 ng/mL) and 1.4 µg/kg (0.7-2.4 µg/kg), respectively, over 10 min. Patients reported low level of pain and good satisfaction with the procedure. CONCLUSIONS: FFB under sedation with Remi-TCI seems to be safe and effective in critically ill patients with spontaneous ventilation. Such results could be the first step towards wider use of Remi-TCI in patients experiencing awkward and/or painful procedures in this setting.

Impact of epidural analgesia on survival in patients undergoing complete cytoreductive surgery for ovarian cancer.

BACKGROUND: Potential benefits of regional analgesia in reduction of cancer recurrence have been reported for breast and prostate cancer. The aim of this study was to evaluate the influence of regional analgesia on recurrence-free survival and overall survival in patients with advanced-stage ovarian cancer (ASOC) following complete cytoreduction. PATIENTS AND METHODS: This is a retrospective study of 104 patients who had undergone complete cytoreduction for ASOC between 01/2007 and 12/2009: 51 with patient controlled epidural analgesia (PCEA) and 53 without PCEA. RESULTS: No significant difference was found between the two groups in terms of overall survival, while there was a trend in favour of PCEA for disease free survival. CONCLUSION: In our study, regional analgesia had no clear impact on cancer recurrence. More studies on this subject are warranted in order to determine the possible impact of regional analgesia on ASOC.

Influence of real-time Bayesian forecasting of pharmacokinetic parameters on the precision of a rocuronium target-controlled infusion.

INTRODUCTION: Bayesian forecasting has been shown to improve the accuracy of pharmacokinetic/pharmacodynamic (PK/PD) models by adding measured values to a population model. It could be done in real time for neuromuscular blockers (NMB) using measured values of effect. This study was designed to assess feasibility and benefit of Bayesian forecasting during a rocuronium target-controlled infusion (TCI). METHODS: After internal review board (IRB) approval and informed consent, 21 women scheduled for breast plastic surgery were included. Anesthesia was maintained with propofol, alfentanil, and controlled ventilation through a laryngeal mask. Rocuronium was delivered in TCI with Stanpump software and the Plaud population model. The target effect was 50% blockade until insertion of breast prosthesis; thereafter it was set to 0%. Response to train of four (TOF) at adductor pollicis was recorded using a force transducer. In ten patients, drug delivery was based on the population model. In the others, repeated measures values were entered in the software, and the PK model was adjusted to minimize the error in predicted effect. Model precision was compared between groups using mean prediction error and mean absolute prediction error. RESULTS: At target 50%, model accuracy was not improved with Bayesian adjustments; conversely, post-infusion errors were significantly decreased. The first two measures had the most influence on the model changes. DISCUSSION: Below clinical utility, such adjustments may be used to explore cofactors influencing interindividual and intraindividual variability in NMB dose-response relationship. Similar tools may also be developed for drugs in which a quantitative effect is available, such as electroencephalography (EEG) for hypnotics. IMPLICATION: Real-time Bayesian forecasting combining measured values of effect with a population model is suitable to guide NMB-agent delivery using Stanpump software.

A comparison of propofol and remifentanil target-controlled infusions to facilitate fiberoptic nasotracheal intubation.

INTRODUCTION: Successful fiberoptic intubation requires both patient comfort and good intubating conditions. In this study we compared the efficacy and ease of titration of propofol (P) and remifentanil (R) target-controlled infusions (TCI) during fiberoptic intubation. METHODS: Sixty patients requiring fiberoptic nasotracheal intubation were randomized to receive (P) or (R) effect-site TCI. After topical anesthesia, TCI was set to 2.5 microg/mL (P) or 1.5 ng/mL (R) then titrated by 1 microg/mL (P) or 0.5 ng/mL (R) increments according to patient reactions. Targets and level of sedation were recorded at each step as well as total dose, number of adjustments, intubating conditions, discomfort, and recall assessed after surgery. RESULTS: Intubation duration, success rate, and number of increments did not differ between groups. Intubating conditions were good in both groups, with a final target of 3.9 +/- 1.4 microg/mL (P) or 2.4 +/- 0.8 ng/mL (R) (total dose 142 +/- 55 mg and 77 +/- 27 microg, respectively). There was no difference in minimal SpO(2) and maximal end-tidal CO(2) after intubation. No laryngospasm or significant hemodynamic instability was observed. There was one major hypoxemia due to obstructive apnea in group P. Patients in group P were significantly more sedated and less cooperative. Recall was more frequent in group R, whereas pain scores were equally low in both groups. CONCLUSION: Both R and P TCI can be rapidly titrated to achieve good intubating conditions and patient comfort. R allows for more patient cooperation, making it safer when spontaneous ventilation is paramount.

Does spectral entropy reflect the response to intubation or incision during propofol-remifentanil anesthesia?

BACKGROUND: Spectral entropy is an electroencephalogram-based monitoring technique with a frequency band enlarged to include the electromyogram spectrum, which is intended to help to assess analgesia. Although its correlation with hypnosis has been shown, its performance during a noxious stimulation and the influence of neuromuscular blockade have not been described. METHODS: In this prospective, open, multicenter study, 105 patients received propofol then remifentanil target-controlled infusion for induction of anesthesia, with randomized remifentanil targets ranging from 2 to 8 ng/mL. Half of the patients received neuromuscular blockade. Intubation and incision were used as standard noxious stimulations, motor or hemodynamic responses were recorded, and spectral entropy values before and after stimulations were compared between responders and nonresponders. RESULTS: No difference was found in response entropy (RE), state entropy (SE), or (RE - SE) between patients with or without hemodynamic response to stimulations. Patients with motor response to intubation had higher values of RE, SE, and (RE - SE) both before and after the intubation than patients with no response. These results were confirmed by a prediction probability analysis, showing a significant but weak predictive value of entropy for motor response only. CONCLUSIONS: Entropy predicted a motor response to noxious stimulations but not a hemodynamic response, which limits its usefulness for assessing the analgesic component of anesthesia in paralyzed patients. High values (RE >55) before the stimulation should be avoided in order to decrease the risk of motor response, but lower values might not prevent this response when the opioid concentration is insufficient, despite an adequate hypnosis.

Optimization of hyperthermic intraperitoneal chemotherapy with oxaliplatin plus irinotecan at 43 degrees C after compete cytoreductive surgery: mortality and morbidity in 106 consecutive patients.

BACKGROUND: Peritoneal carcinomatosis (PC), which has hitherto been regarded as a lethal entity, can now be cured with surgery (treating macroscopic tumor seeding) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) (treating residual microscopic disease). The purpose of this study was to analyze the morbidity and mortality of a particular approach associating optimal (R0-R1) cytoreduction, optimal HIPEC combining oxaliplatin and irinotecan, and an optimal homogeneous intraperitoneal temperature of 43 degrees C. METHODS: A total of 106 consecutive patients were included in this prospective phase 2 study. After complete resection of the PC, HIPEC was performed by the Coliseum technique with oxaliplatin (360 mg/m2) combined with irinotecan (360 mg/m2) in 2 L/m2 of 5% dextrose, over 30 minutes at a real intraperitoneal temperature of 43 degrees C. During the hour preceding HIPEC, patients received 5-fluorouracil (400 mg/m2) and leucovorin (20 mg/m2) intravenously, resulting in tritherapy. RESULTS: Postoperative mortality and morbidity rates were 4% and 66%, respectively. The most frequent complications were digestive fistula (24%), lung infection (16%), and severe hematological toxicity (11%). Statistical correlation was evidenced between morbidity and the carcinomatosis score (P = .0008), the number of resected organs (P = .0001), the duration of surgery (P = .0001), and blood loss (P = .0001). CONCLUSIONS: This new approach, optimized in three respects (complete cytoreduction, combination oxaliplatin with irinotecan, and high temperature) has resulted in a relatively high but acceptable incidence of adverse events considering the expected advantage for survival.

Muscle relaxation and increasing doses of propofol improve intubating conditions.

PURPOSE: Muscle relaxants and anesthetics are usually associated during intubation. However, their relative role to facilitate the process is not clearly defined. This study was designed to determine, during intubation: i). the relative role of anesthetics and atracurium-induced neuromuscular block and; ii). the effect of different doses of propofol in the presence of complete muscle block. METHODS: Patients were randomized to four groups and received fentanyl and a standardized anesthetic procedure. Patients from groups high (H; n = 45), medium (M; n = 48) and low (L; n = 47) received 2.5 mg x kg(-1), 2.0 mg x kg(-1), and 1.5 mg x kg(-1) of propofol respectively. Atracurium (0.5 mg x kg(-1)) was then injected and tracheal intubation performed once complete block was achieved at the orbicularis oculi. Patients from group without atracurium (WA; n = 20) received propofol as in group H. Intubation was performed at the expected onset time of action of atracurium. RESULTS: Using the same dose of propofol, the incidence of good or excellent intubating conditions was 35% without atracurium and 95% with atracurium (P < 0.0001). In patients receiving atracurium, clinically acceptable intubating conditions were more frequently achieved in groups receiving the highest propofol doses (group H or M vs group L; P < 0.03). CONCLUSION: Our study confirms the interaction between anesthesia and muscle relaxation to produce adequate intubating conditions. In the conditions described, intubating conditions were more dependent on atracurium-induced neuromuscular blockade than on anesthetics, but both atracurium and propofol improved intubating conditions.