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Intraoperative anaesthesia management in oro-facial cancer surgical patients requiring free flap tissue transfer is evolving. In this paper we updated our intraoperative clinical protocol using our own experience in combination with the latest literature. The main areas of change include videolaryngoscopic awake intubation in case of difficult airway management, combination of regional anaesthesia with peripheral catheter to decrease intraoperative opioid consumption, and postoperative pain and finally opioid free anaesthesia techniques using dexmedetomidine.

Postoperative management of complex cervico-facial cancer tumor removal followed by free flap reconstruction is evolving since its early beginning 20 years ago. Flap surveillance is a major goal in this period, however the management of comorbidities to predict a favorable outcome cannot be neglected. Based on our experience in this field and recent literature we updated our postoperative management protocol which focus on management of different comorbidities to maintain favorable outcome for the graft and the patient.

Hypoalbuminemia in major cancer surgery can lead to postoperative short and long-term complications. Our study was designed to detect albumin variations in three major cancer surgeries: ovarian debulking (DBK), major abdominal gastrointestinal surgery (ABD), and major cervico-facial, or ear, nose and throat cancer surgery (ENT). Single-center prospective study inclusion criteria were non-emergency procedures scheduled to last at least five hours. We performed hourly perioperative monitoring of the patients’ albuminemia and hemoglobinemia. Electronic charts were followed for at least five years for survival analysis. Sixty-three patients were analyzed: 30 in the DBK group, 13 in the ABD group, and 20 in the ENT group. There was a significant difference in albumin decrease between the ENT group and the two others (−19% at six hours in the ENT group versus -49% in the debulking group and −31% in the ABD group (p < 0.05). There was no significant difference between the DBK and ABD groups. The decrease in hemoglobin was not significantly different between the groups, and no significant difference was observed in long-term survival. DBK and ABD surgery yielded significant hypoalbuminemia. Therefore, the extent of decrease in serum albumin is probably not the only etiology of the specific postoperative complications of these major surgeries. No significant difference was noticed in five-year mortality, and no correlation was found in relation to the degree of intraoperative albumin kinetics.

Objective To compare cardiac index (CI) between Proaqt/PulsioFlex® and oesophageal Doppler (OD) and the ability of the PulsioFlex® to track CI changes induced by fluid challenge and secondly to assess the impact of the time interval between two auto-calibrations of PulsioFlex® on the accuracy of the measured CI. Methods In a single hospital, 49 intermediate-risk oncologic abdominal surgery patients were included in an observational study. We measured the cardiac Index (CI) provided by OD and by the Proaqt/PulsioFlex® before and after internal calibration, which were performed randomly at specific intervals after the initial one (30, 60, 90 and 120 min). The ability to track fluid responsiveness was evaluated by measuring stroke volume variation, pulse pressure variation (PPV) and CI before and after a 250 ml fluid challenge and assessed by a receiver operating characteristic curve analysis. Results The percentages of error before calibration were 51, 58, 82, 81% for 30, 60, 90 and 120 min, they were 39, 57, 65, and 54% after calibration. Trending ability is assumed by a 93% concordance rate after applying a 15% exclusion zone. The trend interchangeability rate was 13.75%. The area under the curve for fluid responsiveness measured by PPV and SVV PulsioFlex were respectively 0.67 [0.57–0.77], P Conclusions The Proaqt/Pulsioflex® system is not equivalent to OD for haemodynamic monitoring during non-vascular abdominal surgery in intermediate-risk patients. More studies are required to define the effect of the auto-calibration on the system.

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.

To compare cardiac index (CI) between Proaqt/PulsioFlexIn a single hospital, 49 intermediate-risk oncologic abdominal surgery patients were included in an observational study. We measured the cardiac Index (CI) provided by OD and by the Proaqt/PulsioFlexThe percentages of error before calibration were 51, 58, 82, 81% for 30, 60, 90 and 120min, they were 39, 57, 65, and 54% after calibration. Trending ability is assumed by a 93% concordance rate after applying a 15% exclusion zone. The trend interchangeability rate was 13.75%. The area under the curve for fluid responsiveness measured by PPV and SVV PulsioFlex were respectively 0.67 [0.57-0.77], P0.01 and 0.75 [0.47-0.66], which was not clinically relevant.The Proaqt/Pulsioflex

INTRODUCTION The PiCCO2 is a commonly used monitor, which education remains theoretical and demonstration based. Simulation allows active learning, which may help achieve a better understanding and handling of this device, hence a safer and more effective use. Because of the lack of availability of dedicated simulators and the uselessness of the demonstration mode of monitors for simulation purpose, simulation remains seldom used. We will describe a novel use of the PiCCO2 for simulation training and its experiment in high-fidelity simulation (HFS). METHODS A standard PiCCO2 was modified with software allowing its transformation into a simulator. The values displayed on the screen were managed in real time by an operator using a standard laptop linked to the monitor and using a standard disposable catheter set to execute simulated transpulmonary thermodilution. Nineteen volunteers were requested to assess the realism of the device during scenarios in which the PiCCO2S (simulator) was used in an HFS environment, with a mannequin reproducing a septic shock condition. RESULTS Two experimental sessions were made. PiCCO2S was used in the contextualized setting of HFS, which allowed a good interactivity between the device and its users. Participants had a positive perception of the realism as well as the method's adequacy to achieve a better understanding of the PiCCO2. CONCLUSIONS The PiCCO2S could be obtained from a serial device. Its integration in HFS provided a realistic handling of the device. A built-in simulation mode into serial medical devices may give users an easy access to training.

Background Patients undergoing free flap reconstruction after head and neck cancer may develop free flap complications. In the perioperative period, haemoglobin content and oxygen tissue saturation (StO2) measured directly on the free flap reflect peripheral tissue oxygenation. However, in this type of surgery, StO2 cannot always be applied directly or proximate to the free flap. The aim of this study was to assess the possible value of StO2 measured at the thenar eminence and other 24 hour perioperative factors on free flap complications. Methods Inclusion criteria corresponded to patients with head and neck cancer with free flap surgery in whom direct StO2 could not be monitored on the flap nor in its peripheral area. Patient characteristics and intraoperative data, such as haemoglobin and fluid management, were prospectively collected. StO2 was measured remotely on the thenar eminence. Data were collected for 24 hours and free flap complications were recorded for up to 15 days after surgery. Patients were thereafter classified into two groups: with or without free flap complications and the data were compared in consequence. Results Forty consecutive patients were prospectively included. Ten patients had postoperative free flap complications and were compared to the 30 other patients without complications. The haemoglobin level at the reperfusion of the flap: (AUC 0.80 [0.65–0.91], threshold 9.9 g/dL, P Conclusion In head and neck complex oncologic reconstructive surgery, haemoglobin and BMI were the most sensitive tools for predicting postoperative free flap complications, while thenar eminence StO2 was not.

Background Preoperative screening includes clinical examination and tests. Systematic prescription leads to excessive tests. We conducted an observational retrospective study to assess the success of implementing a protocol-guided prescription procedure for preoperative tests (PTs). We compared the number of PTs prescribed for scheduled surgery before and after the implementation of local guidelines with a specific method. Methods Local guidelines for prescribing PTs based on the French Society of Anaesthesia's recommendations were developed, validated by the anaesthesia team and actively implemented. The implementation procedure was complex and based on the application of sociologic concepts to facilitate PT prescriptions in accordance with the protocol. All PTs (except for children and emergency surgeries) prescribed over a one-week observation period were analysed before and after protocol implementation, respectively in 2011 and 2013. Results Two hundred and ninety-two patient files were analysed: 157 in 2011 and 135 in 2013. Ninety-one percent of the prescriptions were in accordance with the recommendations in 2013. Excessive prescribing decreased significantly after the implementation of recommendations (7.1% versus 20.7%, P Conclusion We observed excellent adherence to the prescription protocol for PTs. The method used to implement the protocol was successful. A future evaluation should be undertaken to confirm these results over the long-term.

Introduction La chirurgie robotique est en plein essor. La gestion des urgences vitales (medicales et laparoconversions) est compliquee par les contraintes ergonomiques specifiques du robot ce qui est prejudiciable pour la securite des patients [1] . La simulation permet aux equipes d’etudier ces contraintes, de les anticiper et d’adapter les protocoles. Nous presentons les premiers resultats d’une methode de simulation peu couteuse et adaptable. Materiel et methodes Six heures de simulation dans la salle d’operation dediee a cette chirurgie ont ete organisees avec les referents en chirurgie robotique de Gustave-Roussy. Un mannequin basse-fidelite Gaumard® hybride avec un simulateur procedural de type « pelvi trainer » permettant l’usage reel du robot et un simulateur de parametres vitaux Prosim 8 (Fluke Medical®) ont ete utilises. Le robot Da Vinci Xi© d’Intuitive Surgical® a ete deploye dans les conditions ergonomiques et materielles reproduisant celles d’un patient opere d’une chirurgie robotique pelvienne. Trois scenarios ont ete etudies : laparoconversion en urgence vitale pour hemorragie (LCV), arret cardiorespiratoire peroperatoire (ACR), et retrait d’une pince bloquee (RPB). Une check list de retrait des bras du robot en urgence vitale entierement inedite a ete etudiee lors de ces scenarios. Resultats Des elements specifiques non encore envisages ont ete identifies et des mesures correctrices ont ete immediatement appliquees : – en cas de LCV : necessite d’un ecarteur abdominal disponible systematiquement dans en salle d’operation, modification de la position des bras du robot pour le retrait en urgence, necessite de former les internes de chirurgie au retrait urgent du robot ; – en cas d’ACR : difficulte de poses d’electrodes de defibrillateur ; l’absence de coordination entre le retrait du robot et le debut de la reanimation a entraine un temps de no flow de 70 s. La mise en place de mesures correctrices a permis de reduire ce temps a 20 s lors d’un 2e scenario ; – en cas de RPB : localisation de l’ouitl specifique diffusee et validee. Manipulation de celui-ci repetee en situation non urgente par les chirurgiens et les IBODE. Par extension la situation de deblocage en cas de panne electrique a ete abordee. Le contenu de la check list a ensuite ete modifie et valide en consequence ( Fig. 1 ). Discussion Une simulation in situ hybride low cost, sans mannequin haute-fidelite, mais rapide a mettre en œuvre, a permis de reproduire les conditions de la chirurgie pelvienne robotique avec realisme. Cela a rendu possible l’etude d’une check list specifique et de son utilisation, ainsi que l’analyse precise des contraintes et des obstacles a la gestion des urgences restees latentes jusque-la. Ce type de simulation interprofessionnelle permettrait de mieux apprehender les situations critiques avant de demarrer l’activite de chirurgie robotique, et de former les divers acteurs, efficacement et a faible cout. La methode sera renouvelee en chirurgie ORL avec les memes objectifs et pourrait confirmer son efficacite. Une check list specifique sera aussi developpee.

Introduction La litterature internationale recommande l’abandon de la prescription systematique d’examens complementaires pre-interventionnels au profit d’une prescription limitee, raisonnee et basee sur des signes d’appel cliniques ou anamnestique [1] , [2] . Un audit des prescriptions des examens preoperatoires en vue d’une chirurgie programmee a ete realise au sein de notre etablissement base sur les recommandations formalisees d’experts (RFE) de la Societe francaise d’anesthesie et de reanimation (SFAR) et adapte aux chirurgies pratiquees. L’objectif de cette etude etait de comparer les prescriptions preoperatoires d’examens complementaires en vue d’une chirurgie programmee et leur cout avant et apres la mise en place de recommandations locales. Materiel et methodes Tous les patients hospitalises dans notre structure signaient un consentement eclaire d’utilisation des donnees medicales a leur admission. Un protocole de prescription d’examens preoperatoires decoulant du referentiel de la SFAR etait elabore, valide par tous les membres de l’equipe d’anesthesie de l’etablissement et mis en place. Une analyse retrospective de l’ensemble des examens preoperatoires prescrits pendant une semaine representative de l’activite chirurgicale avant et apres mise en place du protocole, respectivement en 2011 et 2013, a ete effectuee. Les patients pediatriques et devant subir une intervention en urgence n’ont pas ete inclus. L’analyse comparative des donnees qualitatives a ete realisee avec des tests de type Fisher ou Chi2 selon le cas. Les resultats sont presentes en nombre de patients et pourcentage. Une analyse comparative du cout des prescriptions par exces a ete realisee sur la base du cout unitaire de chaque examen communique par les laboratoires de notre etablissement. Resultats Deux cent quatre-vingt douze dossiers ont ete analyses ; 157 en 2011 et 135 en 2013. 91 % des prescriptions etaient conformes aux recommandations en 2013 contre 77 % en 2011. La prescription d’examen par exces apres mise en place des recommandations etait de 7,1 % en 2013 contre 20,7 % en 2011 (p Tableau 1 ). Discussion Dans cette etude les mesures de mise en place du protocole local base sur un referentiel national ont permis une diminution significative du nombre et du cout des prescriptions d’examens preoperatoires. Une etude multicentrique serait necessaire afin de confirmer les resultats de cette etude et permettrait de juger de l’impact economique de la mise en place du referentiel.

Background Transpulmonary thermodilution allows the measurement of cardiac index for high risk surgical patients. Oncologic patients often have a central venous access (port-a-catheter) for chronic treatment. The validity of the measurement by a port-a-catheter of the absolute cardiac index and the detection of changes in cardiac index induced by fluid challenge are unknown. Methods We conducted a monocentric prospective study. 27 patients were enrolled. 250 ml colloid volume expansions for fluid challenge were performed during ovarian cytoreductive surgery. The volume expansion-induced changes in cardiac index measured by transpulmonary thermodilution by a central venous access (CIcvc) and by a port-a-catheter (CIport) were recorded. Results 23 patients were analyzed with 123 pairs of measurements. Using a Bland and Altman for repeated measurements, the bias (lower and upper limits of agreement) between CIport and CIcvc was 0.14 (−0.59 to 0.88) L/min/m2. The percentage error was 22%. The concordance between the changes in CIport and CIcvc observed during volume expansion was 92% with an r = 0.7 (with exclusion zone). No complications (included sepsis) were observed during the follow up period. Conclusions The transpulmonary thermodilution by a port-a-catheter is reliable for absolute values estimation of cardiac index and for measurement of the variation after fluid challenge. Trial Registration clinicaltrials.gov NCT02063009

Background/Aim: Peritoneal carcinomatosis (PC) is a pernicious event associated with a dismal prognosis. Complete cytoreductive surgery (CCRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is able to yield an important survival benefit but at the price of a risky procedure inducing potentially severe complications. Postoperative peritonitis after abdominal surgery occurs mostly when the digestive lumen and the peritoneum communicate but in rare situation, no underlying digestive fistula can be found. The aim of this study was to report this situation after CCRS plus HIPEC, which has not been described yet and for which the treatment is not yet well defined. Patients and Methods: Between 1994 and 2012, 607 patients underwent CCRS plus HIPEC in our tertiary care center and were retrospectively analyzed. Results: Among 52 patients (9%) reoperated for postoperative peritonitis, no digestive fistula was found in seven (1%). All had a malignant peritoneal pseudomyxoma with an extensive disease (median Peritoneal Cancer Index: 27). The median interval between surgery and reoperation was 8 days [range: 3-25]. Postoperative mortality was 14%. Five different bacteriological species were identified in intraoperative samples, most frequently Escherichia coli (71%). The infection was monobacterial in 71%, with multidrug resistant germs in 78%. Conclusions: Postoperative peritonitis without underlying fistula after CCRS plus HIPEC is a rare entity probably related to bacterial translocation, which occurs in patients with extensive peritoneal disease requiring aggressive surgeries. The principles of treatment do not differ from that of other types of postoperative peritonitis.