Impact of take-home messages written into slide presentations delivered during lectures on the retention of messages and the residents' knowledge: a randomized controlled study.

BACKGROUND: Lectures with slide presentations are widely used to teach evidence-based medicine to large groups. Take-home messages (THMs) are poorly identified and recollected by students. We investigated whether an instruction to list THMs in written form on slides would improve the retention thereof by residents, and the residents' level of knowledge, 1 month after lectures. METHODS: Prospective blinded randomized controlled study was conducted. Twelve lectures (6 control and 6 intervention lectures) were delivered to 73 residents. For the intervention lectures, the lecturers were instructed to incorporate clear written THMs into their slide presentations. The outcomes were ability of resident to recollect THMs delivered during a lecture (as assessed by accordance rate between the lecturers' and residents' THMs) and knowledge (as assessed by multiple choice questions (MCQs)). RESULTS: Data for 3738 residents' THMs and 3410 MCQs were analyzed. The intervention did not significantly increase the number of THMs written on slides (77% (n = 20/26), 95% CI 56-91 vs 64% (n = 18/28), 95% CI 44-81, p = 0.31) nor THMs retention (13% (n = 238/1791), 95% CI 12-15 vs 17% (n = 326/1947), 95% 15-18, p = 0.40) nor knowledge (63.8 ± 26.2 vs 61.1 ± 31.4 /100 points, p = 0.75). In multivariable analyses performed with all THMs written on slides from the two groups, a superior knowledge was associated with notetaking during lectures (OR 1.88, 95% CI 1.41-2.51) and THMs retention (OR 2.17, 95% CI 1.54-3.04); and THMs retention was associated with written THMs (OR 2.94, 95% CI 2.20-3.93). CONCLUSIONS: In lectures delivered to residents, a third of the THMs were not in written form. An intervention based on an explicit instruction to lecturers to provide THMs in written form in their slide presentations did not result in increased use of written THMs into the slide presentation or improvement of the THMs retention or level of knowledge. However, we showed that there was a strong positive association between writing THMs on a slide, retention of THMs and residents' knowledge. Further researches are needed to assess interventions to increase written THMs in lectures by faculty. TRIAL REGISTRATION: ClinicalTrials.gov NCT01795651 (Fev 21, 2013).

Compared effects on cerebral oxygenation of ephedrine vs phenylephrine to treat hypotension during carotid endarterectomy.

While both ephedrine and phenylephrine are currently used to treat hypotension occurring during carotid endarterectomy (CEA) under general anaesthesia, phenylephrine may have deleterious effects on the cerebral watershed, due to its exclusively vasoconstrictive action. In this controlled, double-blind randomised trial, we compared the effects of ephedrine and phenylephrine administered in a standardised algorithm to treat the first hypotensive event occurring since induction of anaesthesia until carotid cross-clamping. The algorithm consisted of 1-to-3 boluses of 6 mg of ephedrine or 50 µg of phenylephrine, after a goal-directed fluid therapy. In case of failure, the treatment switched to the other study drug. Cerebral tissue oxygen saturation (SctO2 ) was monitored by near infrared spectroscopy (NIRS), and the primary outcome was the restoring effect of SctO2 (ipsilateral to surgery) to baseline values. Secondary postoperative outcomes were: contralateral SctO2 , neurological outcomes, and plasma S100B protein measured at discharge from post-anaesthesia care unit. Ephedrine treatment provided a higher rate of restoration of ipsilateral SctO2 than phenylephrine (93.2% vs 85.1%, P=.034); this was also noted for contralateral SctO2 (93.5% vs 90.7%, P=.026). The gain in SctO2 on the lowest value during hypotension was also higher under ephedrine than phenylephrine (6.4% vs 4.3% ipsilateral, 5.1% vs 4% contralateral), but not significantly so. Clinical outcomes were unaffected by the treatment, but S100B protein plasma concentration was higher in the phenylephrine group. To conclude, this pilot trial, focusing on intermediate outcomes, suggests that ephedrine should be preferred to phenylephrine to treat hypotension during CEA.

Bilateral sternal infusion of ropivacaine and length of stay in ICU after cardiac surgery with increased respiratory risk: A randomised controlled trial.

BACKGROUND: The continuous bilateral infusion of a local anaesthetic solution around the sternotomy wound (bilateral sternal) is an innovative technique for reducing pain after sternotomy. OBJECTIVE: To assess the effects of the technique on the need for intensive care in cardiac patients at increased risk of respiratory complications. DESIGN: Randomised, observer-blind controlled trial. SETTING: Single centre, French University Hospital. PATIENTS: In total, 120 adults scheduled for open-heart surgery, with one of the following conditions: age more than 75 years, BMI >30 kg m, chronic obstructive pulmonary disease, active smoking habit. INTERVENTION: Either a bilateral sternal infusion of 0.2% ropivacaine (3 ml h through each catheter; 'intervention' group), or standardised care only ('control' group). Analgesia was provided with paracetamol and self-administered intravenous morphine. MAIN OUTCOME MEASURES: The length of time to readiness for discharge from ICU, blindly assessed by a committee of experts. RESULTS: No effect was found between groups for the primary outcome (P = 0.680, intention to treat); the median values were 42.4 and 37.7 h, respectively for the control and intervention groups (P = 0.873). Similar nonsignificant trends were noted for other postoperative delays. Significant effects favouring the intervention were noted for dynamic pain, patient satisfaction, occurrence of nausea and vomiting, occurrence of delirium or mental confusion and occurrence of pulmonary complications. In 12 patients, although no symptoms actually occurred, the total ropivacaine plasma level exceeded the lowest value for which neurological symptoms have been observed in healthy volunteers. CONCLUSION: Because of a small size effect, and despite significant analgesic effects, this strategy failed to reduce the time spent in ICU. TRIAL REGISTRATION: EudraCT (N°: 2012-005225-69); ClinicalTrials.gov (NCT01828788).

Positive end-expiratory pressure does not decrease cardiac output during laparoscopic liver surgery: A prospective observational evaluation.

BACKGROUND: Positive end-expiratory pressure (PEEP) has beneficial pulmonary effects but may worsen the hemodynamic repercussions induced by pneumoperitoneum (PNP) in patients undergoing laparoscopic liver resection. However, by increasing intraluminal vena cava (VC) pressures, PEEP may prevent PNP-induced VC collapse. The aim of this study was to test the validity of this hypothesis. METHODS: After IRB approval and written informed consent, 20 patients were evaluated prospectively. Measurements were performed before and after the application of 10 cmH2O PEEP on patients without PNP (Control group) and during a 12 cmH20 PNP. Results are provided as means [95%CI]. Comparison used paired-sample t test. RESULTS: PEEP induced a decrease in CI in Control subgroup (2.3 [2.0-2.6] and 2.1 [1.8-2.4] l min-1 m-2 before and after PEEP. P < 0.05). In contrast, PEEP on a pre-established PNP did not significantly modify cardiac index (CI). Transmural pressure on the abdominal vena cava decreased with PNP but was partly reversed by the addition of PEEP. CONCLUSION: The application of PEEP on a pre-established PNP during laparoscopic liver resection in normovolemic patients did not decrease CI. Analysis of transmural VC pressure variations confirms that the addition of PEEP may prevent the vena caval collapse induced by PNP.

Stress among nurses working in emergency, anesthesiology and intensive care units depends on qualification: a Job Demand-Control survey.

BACKGROUND: The nurse stress literature reports an overwhelming culture of acceptance and expectation of work stressors, ironically linked to the control of the workplace to effectively and proactively manage stress. The stressors involved in delivering "stress management" have been well studied in nursing-related workplaces, especially in acute care settings in accordance with the Karasek Job Demand-Control-Support (JDCS) model. However, little is known about the effects of specificity of an acute care unit and the level of qualifications on stress experienced by nurses. METHODS: A survey using the JDCS model was conducted among 385 nurses working in three different acute care units (anesthesiology, emergency and intensive care unit) from a university hospital. Specific questions explored variables such as gender, acute care units, level of qualification and working experience. RESULTS: Two hundred questionnaires were returned. A high level of job strain was highlighted without a gender effect and in the absence of isostrain. Nurses from acute care units were located in the high stress quadrant of the JDCS model. Conversely, other nurses were commonly located in the "active" quadrant. Independent of acute care settings, the highest level of education was associated with the highest job strain and the lowest level of control. CONCLUSIONS: In an acute care setting, a high level of education was a key factor for high job stress and was associated with a perception of a low control in the workplace, both of which may be predictors of adverse mental health. In particular, the lack of control has been associated with moral distress, a frequently reported characteristic of acute care settings. To enhance the personal and professional outcomes of the advanced registered nurses, strategies for supporting nurses manage daily stressors in acute care are urgently required.

A French Nationwide Survey on Anesthesiologist-Perceived Barriers to the Use of Epidural and Paravertebral Block in Thoracic Surgery.

OBJECTIVES: To explore the barriers to the use of epidural block (EDB) or paravertebral block (PVB) for thoracotomy or thoracoscopy. DESIGN: Cross-sectional ancillary study. SETTING: French nationwide practice survey. PARTICIPANTS: Lead anesthesiologists at centers practicing thoracic surgery completed an online questionnaire. INTERVENTIONS: A 9-item electronic questionnaire regarding perceived barriers to the use of EDB and PVB was developed, including technical factors, nursing factors (training and supervision), and reluctance of non-anesthesiologist colleagues (eg, surgeons, nurses and hospital managers). Descriptive and factorial analyses were conducted, including the current use of the techniques in the model. MEASUREMENTS AND MAIN RESULTS: The questionnaire was answered by 84 of 103 (82%) centers. For both techniques, the most frequently cited barriers were the 4 technical ones and lack of nursing supervision. There was a high rate of do not know/no opinion responses regarding barriers to paravertebral block. The type of center did not influence the responses, but paravertebral block was used more often in university hospitals. Colleague reluctance and time consumption (for both techniques), nursing barriers (for epidural block), and perception of risk and complexity (for paravertebral block), were correlated inversely with actual use. Perception of cost had no influence on practice. CONCLUSIONS: This survey suggested that the use of epidural or paravertebral block to provide analgesia for thoracic surgery might be increased by multimodal actions focused on improved communication with surgical and managerial teams. Paravertebral block, as an emerging technique, still is insufficiently recognized in France.

The Algoplus Score to Assess Acute Postoperative pain in Elderly patients-A Pilot Observational Study.

Standard verbal or analogue scales may not be accurate to assess acute postoperative pain in elderly patients. This study was designed to field test the Algoplus tool, developed specifically for this population and based on observation of patient behavior. Prospective, observational cohort. Single center, French University hospital. Forty-eight patients, aged over 65, scheduled for surgery under general anesthesia, and observed on admission to the postanesthesia care unit, immediately after extubation, during the different steps of analgesic intervention (demand, relief with intravenous opioid titration, plus intermediate measures when relevant), and either at discharge or 3 hours after admission. A numerical rating scale (NRS) was used to guide analgesia. The Algoplus score and the state of alertness or sedation were noted. NRS scores and Algoplus scores were significantly related, and both scores significantly decreased under the effect of analgesia, but the correlation was low. In early observations, the Algoplus score was higher than that predicted by the NRS score, in relation to residual sedation. Female gender tended to lower the Algoplus score compared to the NRS score. When the NRS score exceeded 3/10, indicating the need for analgesic intervention, the Algoplus score was generally lower than the recommended trigger for analgesia (2/5). These results are promising, but further evidence of a clinical benefit to the use of Algoplus for acute postoperative pain is needed. In future studies, scoring should be adjusted to take into account the time from extubation, the state of sedation, and the patient's gender in order to interpret results.

General anaesthetic agents do not influence persistent pain after breast cancer surgery: A prospective nationwide cohort study.

BACKGROUND: It has recently been suggested that propofol exerts a protective effect on the occurrence of persistent pain after breast cancer surgery. We analysed data from a subcohort taken from a multicentre study to validate this information. OBJECTIVE: The objective of this article is to study the role of the agent used for maintenance of general anaesthesia on the occurrence of persistent pain, with adjustment for multiple pre and peri-operative variables using the generalised linear model. DESIGN: A prospective cohort study. SETTING: Four French university hospitals. PATIENTS: Three hundred and twenty-eight and 362 patients with full dataset, depending on the studied outcome. INTERVENTION: Questionnaires sent at the third and the sixth month after surgery. MAIN OUTCOME MEASURES: The risk of persistent postsurgical neuropathic pain (defined by the DN4 questionnaire) within 6 months after surgery, and the intensity of persistent pain at the sixth month. RESULTS: Axillary lymph node harvesting and previous history of peripheral neuropathy were independent risk factors of persistent postsurgical neuropathic pain, although older age was protective. The same independent risk factors, but not age, explained the intensity of persistent postsurgical pain at the sixth month after surgery. We did not find any effect of the general anaesthetic, whether halogenated agent or propofol, using either unadjusted or adjusted analyses based on covariates or propensity score. CONCLUSION: There does not appear to be a role for the anaesthetic protocol in the occurrence of persistent postsurgical pain. Other already well established hypotheses were confirmed. TRIAL REGISTRATION: ClinicalTrials.gov (ref. NCT00812734).

Persistent neuropathic pain after inguinal herniorrhaphy depending on the procedure (open mesh v. laparoscopy): a propensity-matched analysis.

BACKGROUND: A greater incidence of persistent pain after inguinal herniorrhaphy is suspected with the open mesh procedure than with laparoscopy (transabdominal preperitoneal), but the involvement of neuropathy needs to be clarified. METHODS: We examined the cumulative incidence of neuropathic persistent pain, defined as self-report of pain at the surgical site with neuropathic aspects, within 6 months after surgery in 2 prospective subcohorts of a multicentre study. We compared open mesh with laparoscopy using different analysis, including a propensity-matched analysis with the propensity score built from a multivariable analysis using a generalized linear model. RESULTS: Considering the full patient sample (242 open mesh v. 126 laparoscopy), the raw odds ratio for neuropathic persistent pain after inguinal herniorrhaphy was 4.3. It reached 6.8 with the propensity-matched analysis conducted on pooled subgroups of 194 patients undergoing open mesh and 125 undergoing laparoscopy (95% confidence interval 1.5-30.4, p = 0.012). A risk factor analysis of these pooled subgroups revealed that history of peripheral neuropathy was an independent risk factor for persistent neuropathic pain, while older age was protective. CONCLUSION: We found a greater risk of persistent pain with open mesh than with laparoscopy that may be explained by direct or indirect lesion of nerve terminations. Strategies to identify and preserve nerve terminations with the open mesh procedure are needed.

CONTEXTE: On soupçonne que l'incidence de la douleur persistante à la suite d'une hernioplastie inguinale est plus élevée avec la mise en place d'un filet par voie ouverte qu'avec la laparoscopie (transabdominale prépéritonéale), mais encore faut-il clarifier le rôle de la neuropathie. MÉTHODES: Nous avons mesuré l'incidence cumulative de la douleur neuropathique persistante, décrite comme une douleur au site opératoire accompagnée d'éléments neuropathiques déclarés par le patient dans les 6 mois suivant la chirurgie, auprès de 2 sous-cohortes prospectives d'une étude multicentrique. Nous avons comparé la mise en place d'un filet par voie ouverte et la laparoscopie à l'aide de différentes analyses, dont une analyse avec appariement des scores de propension, les scores de propension découlant d'une analyse multivariée générée à partir d'un modèle linéaire généralisé. RÉSULTANTS: En tenant compte de tout l'échantillon de patients (242 soumis à la mise en place d'un filet par voie ouverte c. 126 soumis à la laparoscopie), le rapport des cotes brut pour la douleur neuropathique persistante après l'hernioplastie inguinale était de 4,3. Il a atteint 6,8 à l'analyse par appariement des scores de propension réalisée auprès de sous-groupes réunis de 194 patients soumis à la technique ouverte avec treillis et 125 soumis à la laparoscopie (intervalle de confiance à 95 % 1,5­30,4, p = 0,012). Une analyse des facteurs de risque pour ces sous-groupes réunis a révélé que des antécédents de neuropathie périphérique constituaient un facteur de risque indépendant à l'égard de la douleur neuropathique persistante, tandis que l'avancée en âge a conféré un effet protecteur. CONCLUSION: Nous avons observé un risque plus élevé de douleur persistante associée à la mise en place d'un filet par voie ouverte qu'avec la laparoscopie, ce qui pourrait s'expliquer par des lésions directes ou indirectes aux terminaisons nerveuses. Des stratégies s'imposent pour identifier et préserver les terminaisons nerveuses lors de la mise en place d'un filet par voie ouverte.

[Jugular venous and arterial concentrations of serum S100B protein in patients with severe head injury]. / Concentrations sériques jugulaire et artérielle de la protéine S100B chez les patients victimes d'un traumatisme crânien grave.

It is important for physicians in intensive care units to be able to predict the presence and severity of central nervous system injury in patients with severe head injury (SHI). The extent of S100B elevation has been found to be useful in predicting clinical outcome after brain injury. However, only two studies were realized with jugular venous blood samples. The purpose of our study is to compare the interest between jugular venous and arterial concentrations evaluation of serum S100B protein in patients with SHI. We recruited 17 patients with a SHI, admitted to the intensive care unit. Paired arterial and jugular venous samples were taken at kinetically after injury. S100B median was 0.16 µg/L in arterial and 0.25 µg/L in jugular. This arterio-jugular difference is significant. However, there was any significant arterio-jugular difference in the patients group showing an unfavourable outcome or for the earlier samples (earlier than 24h). We observed there was no significant decrease of S100B in jugular, unlike in arterial, 24h after the head injury in the patients group showing an unfavourable outcome. Determination of S100B concentration in jugular samples appears to be better than in arterial to predict clinical outcome after brain injury.

Cutaneous amitriptyline in human volunteers: differential effects on the components of sensory information.

BACKGROUND: Amitriptyline is effective in relieving neuropathic pain. Its site of action is thought to be supraspinal and spinal, but a peripheral effect on fibers is also suggested. METHODS: This double-blind study examined the effects of transcutaneous amitriptyline diluted in hydroalcoholic solution in healthy young male volunteers. Six treatments were randomly applied on different areas of the skin of the back: amitriptyline at 0 (vehicle), 25, 50, and 100 mm; saline (control); and lidocaine-prilocaine cream as a positive control. Up to 24 h after application, mechanical thresholds for touch and nociception, and thermal thresholds for cold, warm, and heat sensation were recorded for each area. Blood samples were collected to assess plasma levels of amitriptyline. A late recording of the tactile thresholds was performed 1 and 3 weeks after the treatment session. RESULTS: The thresholds for all sensations did not differ between the vehicle and saline. Lidocaine-prilocaine cream displayed a short-lasting anesthetic effect for all sensations, although this was not significant for warm sensation. Amitriptyline, at the three concentrations studied, induced a mild and short-lasting increase of the tactile and mechanical nociceptive thresholds. It significantly decreased cold thresholds (down to 21.8 degrees C, P = 0.01 vs. 27.5 degrees C for control) and heat thresholds (down to 40.1 degrees C, P = 0.004 vs. 43.4 degrees C for control). These two effects were no longer significant after the fourth hour of observation. Amitriptyline did not change warm thresholds. There was no apparent systemic absorption effect of the drug. CONCLUSION: It is hypothesized that amitriptyline has a differential effect on different fiber structures.

The Dose-Dependent Effects of Ketoprofen on Dynamic Pain after Open Heart Surgery.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) can reduce postoperative pain, in both static (i.e., at rest) and dynamic contexts (e.g., during coughing or mobilization), and reduced doses could improve their efficacy/tolerance balance. OBJECTIVES: To test this hypothesis of efficacy after open heart surgery, in which NSAIDs are poorly used, particularly for safety concerns. STUDY DESIGN: Randomized, double-blind trial. SETTING: Single-center, French university hospital. METHODS: Patients. One hundred patients at low risk of postoperative complications undergoing scheduled open heart surgery (97 analyzed). We tested intravenous ketoprofen, at a dose of 0.5 mg/kg-1 every 6 hours during the 48 hours following the end of sedation, after surgery. This standard protocol was compared to a similar one in which half doses were administered, to one with quarter doses, as well as to a placebo group. Analgesia was supplemented by acetaminophen plus self- and nurse-administered intravenous morphine. The primary outcome was the intensity of dynamic pain, assessed over 48 hours on an 11-point numerical rating scale (NRS). RESULTS: Only the full-dose ketoprofen group showed reduced dynamic and static postoperative pain vs. placebo (P < 0.00001 for both). The evolution of dynamic pain suggested a delayed and therefore non-significant effect with the low doses. Ketoprofen did not affect either the postoperative morphine consumption or the tolerance outcomes, such as the volumes of chest tube drainage and the renal function. LIMITATIONS: This pilot trial was undersized to test major tolerance outcomes. CONCLUSIONS: Although we failed to demonstrate any analgesic effects with low doses of ketoprofen, we confirmed the good efficacy/tolerance balance with this propionic NSAID of intermediate COX2-selectivity. Lower doses of NSAIDs, potentiated by a loading dose, should be tested in the future.IRB approval: CPP Sud-Est VI (Clermont-Ferrand, France), on 12/23/2013.Clinical trial registry: EudraCT (2013-003878-27); ClinicalTrials.gov (NCT02180087).Key words: Non-steroidal anti-inflammatory drugs, ketoprofen, cyclooxygenase, pain, postoperative, sternotomy, postoperative rehabilitation, analgesia, side effects.

Tolerance and efficacy of a polyamine-deficient diet for the treatment of perioperative pain.

BACKGROUND: Polyamines have been identified as pain agonists and interact with N-methyl-D-aspartate receptors. A prospective, randomized, multicenter, and blinded phase II clinical trial was conducted to evaluate a polyamine-deficient diet for the treatment of perioperative pain in patients during spinal surgery. METHODS: All analyses followed the intention-to-treat principle. The trial was designed to evaluate the dose-ranging effect of a low polyamine diet with respect to a total (group 1) or partial (group 2) polyamine diet on perioperative pain (7 d before and 5 d after surgery). Pain (numerical scale at rest and motion), quality of life questionnaires (Brief Pain Inventory, EIFEL questionnaire, and Short Form-12 acute questionnaire), and tolerance of and compliance with the nutritional program were measured. RESULTS: Compliance (preoperatively: 100% in group 1 and 83% in group 2; postoperatively: 83% in group 1 and 71% in group 2) and tolerance were good. After 7 d following the diet before surgery, decreased pain was observed in group 1 whereas no effect was observed in group 2 (P = 0.144). This analgesic effect became significant in group 1 in the subgroup of patients with initial high levels of pain (NS ≥ 4) at rest (P = 0.03) and during motion (P = 0.011). Quality of life was significantly improved in group 1 (P = 0.0465). In the postoperative period, pain was significantly decreased in group 1 compared to group 2 at rest (P = 0.022) and during motion (P = 0.029). The effect was significantly better on patients with higher initial pain both at rest (P = 0.013) and during motion (P = 0.005) in group 1 compared to group 2. CONCLUSION: Suppression of polyamines from the diet offers a nutrition-based treatment option for perioperative pain reduction independent of and complementary to typical analgesic approaches.

Pupil diameter during postanesthetic recovery is not influenced by postoperative pain, but by the intraoperative opioid treatment.

STUDY OBJECTIVE: To investigate whether pupil diameter (PD) measured during scotopic conditions is influenced by pain in conscious patients in the early postoperative period. DESIGN: Prospective, observational, cohort study. SETTING: Single-center, postanesthesia care unit (PACU). PATIENTS: Patients scheduled for a surgery during general anesthesia. INTERVENTIONS: Baseline PD was measured the day before surgery. Patients were observed on admission to the PACU, immediately after extubation, during the different steps of analgesic intervention (demand, relief, plus intermediate measures when relevant), and either at discharge or 3 hours after admission. MEASUREMENTS: PD, pain (numerical rating scale), and alertness (Observer's Assessment of Alertness/Sedation scale). MAIN RESULTS: Of 103 patients enrolled, 80 required analgesia in the PACU and completed follow-up. Pain intensity evolved in line with expectations (temporary increase then relief), and alertness increased with time. PD increased from low mean values at admission to the PACU (40% of baseline) to a plateau throughout the rest of the study period (80% of baseline) and was not related to pain intensity. Multivariate analyses suggested that the factors influencing PD (or its value related to baseline) were time since extubation and the type of opioid (remifentanil, sufentanil, or sufentanil at high doses) administered during surgery. CONCLUSIONS: Because of a residual effect of intraoperative opioids and a level of nociceptive stimulation lower than in surgical conditions, PD is not significantly influenced by early postoperative pain or pain relief.

The Role of Psychological Factors in Persistent Pain After Cesarean Delivery.

UNLABELLED: This French multicenter prospective cohort study recruited 391 patients to investigate the risk factors for persistent pain after elective cesarean delivery, focusing on psychosocial aspects adjusted for other known medical factors. Perioperative data were collected and specialized questionnaires were completed to assess reports of pain at the site of surgery. Three dependent outcomes were considered: pain at the third month after surgery (M3, n = 268; risk = 28%), pain at the sixth month after surgery (M6, n = 239; risk = 19%), and the cumulative incidence (up to M6) of neuropathic pain, as assessed using the Douleur Neuropathique 4 questionnaire (n = 218; risk = 24.5%). The neuropathic aspect of reported pain changed over time in more than 60% of cases, pain being more intense if associated with neuropathic features. Whatever the dependent outcome, a high mental component of quality of life (SF-36) was protective. Pain at M3 was also predicted by pain reported during current pregnancy and a history of miscarriage. Pain at M6 was also predicted by report of a postoperative complication. Incident neuropathic pain was predicted by pain reported during current pregnancy, a previous history of a peripheral neuropathic event, and preoperative anxiety. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00812734. PERSPECTIVE: Persistent pain after cesarean delivery has a relatively frequent neuropathic aspect but this is less stable than that after other surgeries. When comparing the risk factor analyses with published data for hysterectomy, the influence of preoperative psychological factors seems less important, possibly because of the different context and environment.

Ketorolac potentiates morphine in postoperative patient-controlled analgesia.

The authors conducted a prospective randomised double-blind comparison of patient-controlled analgesia (PCA), with a combination of morphine and ketorolac versus morphine alone and ketorolac alone in the management of postoperative pain after orthopaedic surgery. Forty-two patients were randomly assigned to three groups. Group 1 was given 1 mg/ml morphine, group 2 was given 3 mg/ml ketorolac and group 3 half-doses of each. After a loading dose of 0.07 ml/kg, PCA was started at an initial setting of 1 ml per demand, with a 10-min lock-out interval and no background infusion. Pain was measured at rest and during movements for 48 h. The combination of morphine and ketorolac was more effective than morphine or ketorolac alone in relieving rest pain throughout the study. The combination was also more effective during movement than either drug alone, but only for the first 24 h. The consumption of morphine and ketorolac was significantly lower when the two drugs were administered together. The incidence of urinary retention was highest in the group given morphine alone. The combination of half-doses of morphine and ketorolac is more effective in controlling postoperative pain than either drug alone. This combination also reduces analgesic consumption and morphine-related adverse events.

Neuropathic aspects of persistent postsurgical pain: a French multicenter survey with a 6-month prospective follow-up.

UNLABELLED: To investigate the role of peripheral neuropathy in the development of neuropathic postsurgical persistent pain (N-PSPP) after surgery, this French multicentric prospective cohort study recruited 3,112 patients prior to elective cesarean, inguinal herniorrhaphy (open mesh/laparoscopic), breast cancer surgery, cholecystectomy, saphenectomy, sternotomy, thoracotomy, or knee arthroscopy. Besides perioperative data collection, postoperative postal questionnaires built to assess the existence, intensity, and neuropathic features (with the Douleur Neuropathique 4 Questions [DN4]) of pain at the site of surgery were sent at the third and sixth months after surgery. In the 2,397 patients who completed follow-up, the cumulative risk of N-PSPP within the 6 months ranged from 3.2% (laparoscopic herniorrhaphy) to 37.1% (breast cancer surgery). Pain intensity was greater if DN4 was positive and decreased with time since surgery; it depended on the type of surgery. In pain-reporting patients, the response to the DN4 changed from time to time in about 1:4 of the cases. Older age and a low anxiety score were independent protective factors of N-PSPP, whereas a recent negative event, a low preoperative quality of life, and previous history of peripheral neuropathy were risk factors. The type of anesthesia had no influence on the occurrence of N-PSPP. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00812734. PERSPECTIVE: This prospective observational study provides the incidence rate of N-PSPP occurring within the 6 months after 9 types of elective surgical procedures. It highlights the possible consequences of nerve aggression during some common surgeries. Finally, some preoperative predispositions to the development of N-PSPP have been identified.

The analgesic effects of a bilateral sternal infusion of ropivacaine after cardiac surgery.

BACKGROUND AND OBJECTIVES: The aim of this study was to assess the effects of a continuous postoperative administration of local anesthetic through 2 catheters placed deeply under fascia at the lateral edges of the sternum, close to the emergence of the intercostal nerves. We focused on pain during mobilization, as this aspect is likely to interact with postoperative morbidity. METHODS: Forty adult patients scheduled for open heart surgery with sternotomy were included in this randomized, placebo-controlled, double-blind study. A continuous fixed-rate infusion of 4 mL/hr of 0.2% ropivacaine or normal saline was administered during the first 48 postoperative hrs. All patients received acetaminophen and self-administered morphine. The efficacy outcomes were as follows: pain score during standardized mobilization and at rest; morphine consumption; spirometry and arterial blood gases; postoperative rehabilitation criteria, and patient satisfaction. Total ropivacaine plasma level was monitored throughout the study. RESULTS: Pain scores were lower in the ropivacaine group during mobilization (P = 0.0004) and at rest (P = 0.0006), but the analgesic effects were mostly apparent during the second day after surgery, with a 41% overall reduction in movement-evoked pain levels. The bilateral sternal block also reduced morphine consumption. It improved the patients' satisfaction and rehabilitation, but no effects were noted on respiratory outcomes. No major adverse effect due to the treatment occurred, but the ropivacaine plasma level was greater than 4 mg/L in 1 patient. CONCLUSIONS: This technique may find a role within the framework of multimodal analgesia after sternotomy, although further confirmatory studies are needed.