Guidelines on perioperative optimization protocol for the adult patient 2023.

OBJECTIVE: The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. DESIGN: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS: Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format. RESULTS: The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. CONCLUSIONS: Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Comparison of four different vascular occlusion tests for assessing reactive hyperemia using near-infrared spectroscopy.

OBJECTIVE: To compare data gathered via four different types of vascular occlusion test (VOT) by using near-infrared spectroscopy. The data may support a standardized method to appropriately measure the postischemic recovery slope, which is currently emphasized as a quantitative marker of the microvascular reserve in septic patients. DESIGN: Prospective study. SETTING: Medical intensive care unit of a university hospital. PATIENTS AND MEASUREMENTS: In 20 healthy volunteers and in 20 septic shock patients, we measured muscle tissue oxygen saturation at the thenar eminence by using near-infrared spectroscopy and performed four different vascular occlusion tests in a random order. A pneumatic cuff was placed around either the upper arm (A) or the forearm (FA). Cuff inflation was maintained either during 3 mins (VOT(A3min) and VOT(FA3min)) or until muscle tissue oxygen saturation decreased to 40% (VOT(A40%) and VOT(FA40%)). RESULTS: In volunteers: 1) During VOT(A3min) and VOT(FA3min), the minimal muscle tissue oxygen saturation was significantly higher than 40% (52% ± 10% and 54% ± 6%, respectively), and 2) the muscle tissue oxygen saturation recovery slopes were steeper with VOT(A40%) and VOT(FA40%) than with VOT(A3min) and VOT(FA3min), respectively. Considering the pooled data obtained during VOT(A3min) and VOT(FA3min) (n = 40), recovery slope negatively correlated with minimal muscle tissue oxygen saturation in volunteers (r² = .46, p < .0001) as in septic patients (r² = .34, p = .0001). Considering the pooled data obtained during 40% VOTs, the recovery slope did not correlate with ischemic time in either group. The overlap of recovery slopes between volunteers and septic patients was small for both 40% VOTs but large for both 3-min occlusion VOTs. CONCLUSION: The comparison of recovery slopes between volunteers and septic patients and the fact that the recovery slope was influenced by the extent of muscle tissue oxygen saturation decrease during ischemia and not by the ischemic time both support the use of a fixed minimal muscle tissue oxygen saturation target (40%) over the use of a fixed ischemic time (3 mins) for assessing reactive hyperemia by using near-infrared spectroscopy.

High N-terminal pro-B-type natriuretic peptide: a biomarker of lung cancer?

BACKGROUND: The level of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is affected by many known factors. Our study aimed to evaluate whether other factors, in particular lung cancer, could be responsible for an increase in NT-proBNP levels in a population with no known risk factors for elevated NT-proBNP. PATIENTS AND METHODS: This study was based on the RIABO (Recueil de l'Ischémie au Bloc Opératoire) database, a single-center registry that prospectively records in elective noncardiac surgery. Patients aged > 75 years and those presenting with 1 or more known risk factors for high NT-proBNP were excluded. Patients were divided into 2 groups according to preoperative NT-proBNP levels: (≥ 125 pg/mL or < 125 pg/mL). RESULTS: Between October 2005 and February 2007, 439 patients were eligible for inclusion. Among 35 patients with lung cancer, 26 (74%) had elevated NT-proBNP (≥ 125 pg/mL), versus 9 (26%) with NT-proBNP < 125 pg/mL (P < .0001). By multivariate analysis, the presence of lung cancer was an independent risk factor for a level of NT-proBNP ≥ 125 pg/mL (odds ratio, 7; 95% CI, 2.9-17; P < .0001). We also observed an independent relationship between NT-proBNP ≥ 125 pg/mL and age, female sex, smoking status, and C-reactive protein levels. CONCLUSION: In our study, patients with lung cancer were 7 times more likely to have elevated NT-proBNP (≥ 125 pg/mL). The presence of lung cancer should therefore be taken into account when interpreting NT-proBNP levels. Further studies are warranted to explore the diagnostic value of this marker in lung cancer and to identify the cause of the elevation.