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This observational study was designed to assess the use of spinal anesthesia with chloroprocaine in the context of ambulatory surgery. A prospective, multicenter, observational study was carried out among 33 private or public centers between May 2014 and January 2015 and adult patients, scheduled for a short ambulatory surgery under spinal anesthesia with chloroprocaine. The primary outcomes were anesthetic effectiveness, defined as performance of the whole surgical procedure without any additional anesthetic agent, and the time to achieve eligibility for hospital discharge. Secondary outcomes were the effect of chloroprocaine on motor and sensory blocks, patients’ satisfaction, and the use of analgesics in the first 24 h after surgery. Among the 615 enrolled patients, 56% were male, the mean age was 47.2 ± 15.2 years, and most patients had an ASA (American Society of Anesthesiologists) status of 1 (63.7%). Main surgical procedures performed were orthopedic (62.6%) and gynecologic (16.1%), and the mean duration of surgery was 26.7 ± 16.7 min. The overall anesthetic success rate was 93.8% (95% CI [91.5%; 95.6%]) for the 580 patients with available data for primary criteria. The failure rate was lower than 7% for all surgical procedures, except for gynecologic surgery (14.8%; 95% CI [8.1%; 23.9%]). The average times of eligibility for hospital discharge and effective discharge were 252.7 ± 82.7 min and 313.8 ± 109.9 min, respectively. The time of eligibility for hospital discharge is defined as the recovery of the patient’s normal clinical parameters and the time of effective discharge is defined as the time for the patient to leave the hospital after surgery. Eligibility for patient’s discharge was achieved more rapidly in private than public hospitals (236.3 ± 77.2 min vs. 280.9 ± 80.7 min, respectively, p

Resume Dans la suite des recommandations diffuse en 2003 par la Societe francaise d’anesthesie et de reanimation (recommandations pour la pratique clinique en ALR, RPC-ALR 2003), detaillant les donnees anatomocliniques et les techniques, une mise a jour etait necessaire en raison des nouvelles techniques et connaissances de nature a modifier les pratiques. Les recommandations formalisees d’experts (RFE) ont axe leurs travaux dans 4 domaines de l’ALR perinerveuse (ALR-PN) : 1. Les medicaments, permettant d’aborder la question des associations d’anesthesiques locaux (AL), des adjuvants et de l’impact de l’ALR echoguidee en termes d’epargne d’anesthesiques locaux. 2. Les ecueils lies au terrain, precisant le cadre d’utilisation des emulsions lipidiques en cas d’intoxication systemique aux AL, la faisabilite d’une ALR chez le patient septique, ou encore sous traitement par un anticoagulant oral direct. 3. Les strategies d’utilisation de l’ALR-PN, dans le contexte de la chirurgie de la hanche, de la chirurgie du membre superieur mais egalement pour la chirurgie de la carotide ou de la thyroide. 4. L’hygiene et la securite, concernant les durees de surveillance ou la sedation associee. Enfin quelques points d’actualisation de la RPC-ALR 2003 sont proposes.

International audience; BACKGROUND: Although being controversial, pregabalin (PGB) is proposed during a short perioperative period to improve pain relief.Comparisons between chronic and short-term users during lumbar spine surgery are lacking. OBJECTIVES: The purpose was to compare opioid requirements and postoperative pain among PGB chronic users and naive patients receiving a 48-hour perioperative administration. STUDY DESIGN: Prospective nonrandomized study. SETTING: Tertiary care hospital. METHODS: Chronic users (group PGB, n = 39) continued their treatment, naive patients (group C, n = 43) received a dose of 150 mg preoperatively and 75 mg/12 hours for 48 hours. Anesthesia and analgesia were standardized. The primary outcome was the cumulative oxycodone consumption at 24 hours, other outcomes included pain scores, DN4 (Douleur Neuropathique 4 Questions) scores, and side effects. RESULTS: Group PGB consumed less oxycodone at 24 hours (median [interquartile range] 10 mg [10-17.5] vs. 20 mg [10-20], P = 0.013], at 48 hours (15 mg [10-20] vs. 20 mg [12.5-30], P = 0.018), and required less intraoperative remifentanil (P = 0.004). Both groups showed similar pain scores during the 48-hour follow-up and at 3 months.Based on multivariate analysis, chronic users of PGB before surgery exhibited lower oxycodone requirements at 24 hours (odds ratio, 3.98; 95% confidence interval, 1.44-7.74; P = 0.008]. No differences were noted regarding side effects and DN4 scores. LIMITATIONS: Nonrandomized study. CONCLUSIONS: Patients chronically treated with PGB required less opioid when compared with a short perioperative administration before spinal surgery. Further prospective studies are required to confirm these results in spinal surgeries.

Sağır, Özlem (Balikesir Author), Introduction More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. Methods and analysis EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. Ethics and dissemination EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369. ©

International audience

Resume Les techniques d’infiltration articulaire se sont developpees pour la chirurgie de la hanche et du genou du fait du caractere moins invasif de ces interventions. D’une etude a l’autre le type et la dose d’anesthesique local ainsi que l’utilisation ou non d’un catheter ou d’un adjuvant varient, expliquant l’heterogeneite clinique des meta-analyses sur le sujet. Les patients ayant une infiltration intra- et/ou periarticulaire ont un meilleur controle de la douleur postoperatoire que ceux qui ne beneficient pas d’une technique d’analgesie locoregionale mais le choix de la technique optimale reste controverse.

Introduction Available short-acting intrathecal anesthetic agents (chloroprocaine and prilocaine) offer an alternative to general anesthesia for short-duration surgical procedures, especially ambulatory surgeries. Factors determining the choice of anesthesia for short-duration procedures have not been previously identified. Methods This observational, prospective, multicenter, cohort study was conducted between July 2015 and July 2016, in 33 private or public hospitals performing ambulatory surgery. The primary objective was to determine the factors influencing the choice of anesthetic technique (spinal or general anesthesia). Secondary outcomes included efficacy of the anesthesia, time to hospital discharge, and patient satisfaction. Results Among 592 patients enrolled, 309 received spinal anesthesia and 283 underwent general anesthesia. In both study arms, the most frequently performed surgical procedures were orthopedic and urologic (43.3% and 30.7%, respectively); 66.1% of patients were free to choose their type of anesthesia, 21.8% chose one of the techniques because they were afraid of the other, 16.8% based their choice on the expected ease of recovery, 19.2% considered their degree of anxiety/stress, and 16.9% chose the technique on the basis of its efficacy. The median times to micturition and to unassisted ambulation were significantly shorter in the general anesthesia arm compared with the spinal anesthesia arm (225.5 [98; 560] min vs. 259.0 [109; 789] min; p = 0.0011 and 215.0 [30; 545] min vs. 240.0 [40; 1420]; p = 0.0115, respectively). The median time to hospital discharge was equivalent in both study arms. In the spinal anesthesia arm, patients who received chloroprocaine and prilocaine recovered faster than patients who received bupivacaine. The time to ambulation and the time to hospital discharge were shorter (p

Postoperative pain, nausea and vomiting are frequent symptoms after tonsillectomy. There have been controversies concerning the advantages and drawbacks of different analgesics in this setting, especially non-steroidal anti-inflammatory drugs, because of potential side effects. We have evaluated the effectiveness and safety of a shift from prednisolone to ibuprofen for postoperative analgesia after tonsillectomy.Data from 1231 children scheduled for tonsillectomy over a period of 30 months were analysed. During the first period, children received a combination of paracetamol-prednisolone with codeine as a rescue therapy; in the second period, they received paracetamol and ibuprofen, with tramadol as a rescue therapy. All children received IV dexamethasone at 0.1mg/kg for antiemetic prophylaxis. The primary end-point was the incidence of severe pain defined as an Objective Pain Scale (OPS) score≥6 at the seventh postoperative day (POD7). Other end-points were postoperative nausea or emesis (PONV), sleep disturbance, oral intake and postoperative haemorrhage and reoperation.Six hundred and seventy-two and 559 children were included in the prednisolone and ibuprofen groups respectively. OPS scores≥6 were observed in 3.1% of cases (95% confidence interval, 2.3-4.2%) on POD7 for the entire study population. Ibuprofen reduced the incidence of OPS scores≥6 on POD7 (relative risk 0.37, 95% CI: 0.18-0.78; P=0.009), OPS scores in the ambulatory unit (P0.001) and POD1 (P0.001), nalbuphine requirements (RR 0.42, 95% CI, 0.34-0.5, P0.0001), and PONV (P=0.01) compared with prednisolone. Ibuprofen enhanced sleep quality on POD0 (P0.0001) and POD7 (P=0.02), and oral intake on POD1 (P0.0001). The incidence of bleeding requiring reoperation was comparable between the two groups (RR 0.8 [95% CI, 0.13-4.78], p=0.8). Predictive factors for an OPS score≥6 at POD7 were OPS score4 on the morning and the evening of POD1 (OR 1.24, 95% CI 1.02-1.49, P=0.03 and OR 1.30, 95% CI 1.12-1.55, P=0.008, respectively) and prednisolone use (OR 2.37, 95% CI 1.06-5.31, P=0.04).The administration of ibuprofen compared to prednisolone improves postoperative comfort in children undergoing ambulatory tonsillectomy without increasing the incidence of side effects.

Resume Anticiper le traitement de la douleur est une des cles du soulagement de la douleur prolongee. Le protocole analgesique doit etre initie en preoperatoire et favoriser les combinaisons synergiques. Les traitements antalgiques chroniques doivent etre poursuivis. Une ordonnance doit etre delivree avant l’intervention avec des explications claires et detaillees sur les prises orales, les horaires, ainsi que les medicaments de secours. Les blocs nerveux peripheriques et/ou les infiltrations avec un anesthesique local de longue duree d’action, combinee a une analgesie multimodale, permettent de prolonger l’analgesie au-dela de la periode postoperatoire immediate. La dexamethasone prolonge la duree de l’analgesie produite par les anesthesiques locaux quel que soit le mode d’administration. Les gabapentinoides ou la ketamine sont utiles, mais sont parfois associes a des effets secondaires. La lidocaine intraveineuse a ete peu evaluee au cours de la chirurgie ambulatoire. Le developpement d’un reseau de suivi pour les patients ambulatoires constitue un moyen pour determiner l’efficacite du traitement antalgique. Ces reseaux peuvent aussi integrer les evaluations fournies a partir de l’analgesie perinerveuse continue et aider a augmenter le nombre de patients chirurgicaux et ambulatoires.

Anxiolytic premedication before non-ambulatory surgery in adult patients may have become of less importance in an era of better preoperative patient information. Moreover, an oral hypnotic given the night before surgery may be as efficient as an anxiolytic for relieving patient anxiety. These two strategies were compared for superiority to a placebo and to each other for non-inferiority.Double-blind, randomized, multicentre study versus placebo. Eight hospitals in France. June 2011 to February 2013.Non-ambulatory consecutive surgical patients undergoing general surgery.Patients received either zopiclone 7.5mg the night before surgery (n=204), or alprazolam 0.5mg the morning of surgery (n=206) and controls received placebo (n=68). Demographic data, preoperative anxiety, fear of surgery and anaesthesia, and mood were assessed the day before surgery using a visual analogue scale, the Spielberger scale and the APAIS scale. In the operating room, anxiety and comfort were assessed in addition to physiological data.Preoperative data did not differ between groups. In the operating room, anxiety and comfort were moderate and did not differ significantly between groups on a 1-10 scale (median [25-75 percentile]): zopiclone: 2 [1-4] and 2.5 [1-5]; alprazolam: 2 [1,4] and 2 [1-5]; placebo: 3 [1-5] and 3 [1-5]. The patients who were more anxious preoperatively remained so in the operating room, irrespective of the treatment received (r=0.31, p0.001). A placebo effect was observed in 38% of patients in the corresponding group. Patients receiving zopiclone reported a significantly better sleep the night before surgery compared to other groups (median: 2 vs. 1, p0.001).Premedication in non-ambulatory surgery is no more effective than a placebo, owing to the very moderate level of anxiety experienced by patients.

Resume L’amygdalectomie est une intervention douloureuse. Le paracetamol seul est insuffisant pour controler la douleur postoperatoire. L’efficacite et les effets secondaires du tramadol dependent de sa vitesse de transformation par le CYP2D6 fonction de la pharmacogenomie. La ketamine a la dose de 0,3–0,5 mg/kg en bolus unique constitue une strategie antihyperalgesique adaptee. Le nefopam, egalement dote de propriete antihyperalgesique, n’est utilisable que chez l’adulte. Les AINS sont efficaces et reduisent egalement l’incidence des vomissements. Il existe une controverse sur le risque hemorragique lie a leur administration postoperatoire. Ce risque peut etre minimise par l’emploi d’inhibiteurs selectifs des COX-2. La dexamethasone diminue egalement la douleur et les nausees et vomissements postoperatoires. Son impact sur le risque hemorragique est egalement discute. La codeine n’est plus disponible et l’action de l’oxycodone depend egalement de son metabolisme par le CYP2D6. L’analgesie est donc basee essentiellement sur les non opiaces paracetamol et AINS en l’absence de contre-indication. La dexamethasone et les setrons ont un fort impact sur les NVPO, le tramadol voire les opiaces peuvent etre utilises en recours.

Postoperative and acute pain remains uncontrolled in many instances, leading to the risk of development of chronic pain syndromes. After tissue damage, activation of postsynaptic NMDA receptors, also induced by opioid administration, plays a key role in postoperative pain sensitization, allodynia, and hyperalgesia. Pain intensity may depend on sex, age, anxiety, and genetic factors but in clinical practice, surgical procedure is the main determinant of pain, although pain may vary from one patient to one another. Serial pain measurements are mandatory to assess pain intensity and to guide pain treatment. They are based on unidimensional simple pain scales. Multimodal analgesia combining opioid and non-opioid agent and regional block or infiltration is the rule postoperatively, although evidence is sometimes lacking to support all the combinations commonly used. Opioids should be used on demand while other agents are administered systematically. Non-steroidal anti-inflammatory drugs decrease opioid demand as well as paracetamol although to a less extend. Antihyperalgesic agents including NMDA blockers (ketamine) and α‎2-δ‎ ligands (gabapentin, pregabalin) have an opioid-sparing effect and may prevent the occurrence of chronic pain syndrome after surgery. Regional blocks and infiltration provide good quality analgesia but the balance between advantages and drawbacks of central block need to be evaluated carefully for each surgical procedure.

Ketamine and nefopam has been documented to decrease pain intensity and improve rehabilitation after total knee arthroplasty (TKA). We conducted a follow-up study of a previously randomized clinical trial to determine the prevalence and risk factors of chronic pain 1 year after TKA and to assess the role of perioperative administration of ketamine and nefopam.The original randomized, double-blind trial evaluated postoperative pain in 75 patients scheduled for TKA who received either a 48-hour infusion of ketamine or nefopam compared with placebo. The current study has evaluated patients at 6 and 12 months for the presence of chronic pain defined as a visual analogue scale ≥40 mm during a stair-climbing test. Other outcomes were incidence of neuropathic pain evaluated (DN4 score), active flexion of the knee, and functional outcome (KOOS-PS score).A total of 69 patients completed the trial. The prevalence of chronic pain at 12 months was 17.4% (95% confidence interval [CI], 10.2%-27.9%) without difference between the ketamine (12.5%), nefopam (13.7%), and placebo groups (26.1%). Prevalence of neuropathic pain was 10.2% (95% CI, 3%-17.3%). Ketamine reduced DN4 scores (P=0.02), increased knee flexion (P=0.0007), and KOOS-PS scores (P0.0001) compared with placebo. A visual analogue scale score ≥60 mm in the postoperative period was the only risk factor associated with the occurrence of chronic pain (odds ratio 4.54; 95% CI, 1.17-17.67).After TKA, the intensity of postoperative pain is a risk factor of chronic pain on movement. Intraoperative ketamine seems to improve long-term results of rehabilitation in this setting.

Resume La rachianesthesie demeure sous-utilisee en ambulatoire. La prolongation du bloc anesthesique est une des raisons evoquees. La disponibilite d’agents possedant une cinetique d’effet rapide, adaptee aux contraintes de l’ambulatoire, est un argument qui plaide en faveur de la rachianesthesie ambulatoire. La chirurgie ambulatoire ne majore pas les effets secondaires d’une rachianesthesie lorsque celle-ci est adaptee a la situation clinique du patient et a l’intervention. Les doses de bupivacaine de sufentanil doivent etre respectivement inferieures a 10 mg et 5 μg, l’obtention d’un bloc lateralise de reduire la dose. La chloroprocaine et la prilocaine sont adaptees a une chirurgie sous-ombilicale de duree respectivement inferieure a 60 min et 90 min permettant une sortie precoce du patient. Il faut egalement utiliser des aiguilles atraumatiques de faible calibre, faire en sorte que le patient vide sa vessie avant l’intervention, verifier le residu vesical en SSPI, ne pas effectuer un remplissage vasculaire excessif, anticiper l’analgesie postoperatoire et prevenir les nausees et vomissements.

International audience; 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.

Resume Objectifs L’insertion systematique d’une sonde gastrique (SG) n’est pas recommandee en chirurgie colorectale. Certains facteurs peuvent influencer le recours secondaire a l’aspiration digestive. L’objectif de cette etude a ete de determiner les facteurs de risques de mise en place postoperatoire de SG. Patients et methodes Etude observationnelle sur 290 patients operes d’une chirurgie colorectale avec rehabilitation precoce : immunonutrition, analgesie peridurale thoracique (APD), prevention des nausees-vomissements, ablation de sonde urinaire, absence de SG et de drainage, kinesitherapie respiratoire, mobilisation et realimentation protocolees et magnesium oral. Le critere principal de jugement etait la pose d’une SG pour vomissements et distension abdominale. L’analyse univariee a inclus : âge, sexe, index de masse corporelle (IMC), classe American Society of Anesthesiologist Physical Status Classification System (ASA), duree et site chirurgical, temperature (T°), duree d’APD et de mobilisation, remplissage, diabete, neoplasie, cardiopathie, bronchopneumopathie chronique obstructive (BPCO), realisation d’une stomie, abord cœlioscopique ou non, conversion en laparotomie, administration de droperidol, transfusion, nutrition parenterale. Une regression logistique (p ≤ 0,1 en univariee) a determine les facteurs predictifs de pose de SG. Resultats Sur 277 patients analyses, l’incidence de SG etait de 10,5 % (IC95 %, 7,4–14,6 %). L’analyse univariee a retrouve comme facteurs de risque : IMC, scores ASA > 2, duree d’intervention, de mobilisation, d’APD, resections rectales, sigmoides, droperidol, transfusion, nutrition parenterale, T° en surveillance postinterventionnelle (SSPI) Discussion Denutrition preoperatoire et hypothermie peroperatoire retardent la reprise de l’alimentation orale. Leurs corrections et l’administration postoperatoire de droperidol sont susceptibles de faciliter la reprise de l’alimentation orale.

Introduction The objective of this investigation was to evaluate the practice of spinal anaesthesia among French anaesthetists in inpatient and outpatient settings. Methods and materials A questionnaire was sent to members of the French Association of Anaesthetists involved in regional anaesthesia during the first 4 months of 2015. The questionnaire included items on the practice of spinal anaesthesia (type of needle, local anaesthetic available, puncture and disinfection techniques, etc.) and on the anaesthetic techniques usually used in 5 surgical situations eligible for outpatient surgery (knee arthroscopy, inguinal hernia, transobturator tape, haemorrhoids, varicose veins in the lower limbs). Results Responses from 703 anaesthesiologists were analysed. Spinal anaesthesia was usually performed in a sitting position (76%) using a Whitacre needle (60%) with a 25 G (57%) diameter. Ultrasound before puncture was reported in 26% of cases due to obesity or spinal abnormalities. Among the 5 surgical situations eligible for outpatient spinal anaesthesia, the technique was typically proposed in 29–49% of cases. Bupivacaine was the most used local anaesthetic. Concerns over delays in attaining readiness for hospital discharge, urine retention, operation length, and surgeon's preference were the main reasons for choosing another anaesthetic technique in these situations. Discussion New local anaesthetics are beginning to be used for outpatient spinal anaesthesia due to their interesting pharmacodynamic profile in this context. This study will provide a basis for evaluating future changes in practice.

Resume La cure de hernie inguinale est une intervention extremement frequente dont la prise en charge ambulatoire doit etre privilegiee. Une bonne connaissance de l’anatomie de la paroi abdominale est necessaire pour comprendre le type de chirurgie pratiquee et adapter la technique d’anesthesie locoregionale qui assure la meilleur qualite d’anesthesie et d’analgesie postoperatoire. Plusieurs approches sont possibles telles que la rachianesthesie (unilaterale), les instillations (pour les techniques cœlioscopiques), les infiltrations parietales, le bloc ilio-inguinal et iliohypogastrique, le bloc du plan abdominal transverse (TAP bloc), voire le bloc paravertebral. Toutes ces techniques beneficient de l’apport de l’echoguidage. La prise en charge ambulatoire implique egalement la prevention de la retention d’urines et des nausees-vomissements postoperatoires.

Background and Objectives: Ultrasound guidance is increasingly used for catheter insertion and could make it more complicated to guarantee aseptic insertion of catheters. The current study evaluated the incidence of colonization of ultrasound-guided perineural catheter (US-PNC) placed for postoperative analgesia. Methods: We evaluated prospectively for 14 months 760 ultrasound-guided catheters in a single center placed under sterile conditions. Quantitative culture of all the catheters was performed after withdrawal. Colonization was defined as ≥103 colony-forming units/mL. Infection was defined as the isolation of the same microorganism from the colonized catheter and from blood culture and/or culture of an abscess. Univariate and multivariate logistic regression analyses were performed to determine the independent risk factors of US-PNC colonization. Results: Incidences of colonization and infections were 10.4% (95% confidence interval [95% CI], 8.2%-14.4%) and 0.13% (95% CI, 0%-3.8%), respectively, in a total of 747 catheters. Coagulase-negative staphylococci colonization was documented in 69% of the colonized catheters. Local inflammation was more frequently noted when catheters were colonized (26.9% [95% CI, 15.2%-38.7%] versus 8.1% [95% CI, 4.2%-11.9%], P = 0.005). Independent factors for ultrasound-guided catheter colonization were duration of catheter placement more than 48 hours (odds ratio [OR], 4.9; 95% CI, 1.1-12.7; P = 0.003), diabetes (OR, 2.3; 95% CI, 1.4-9.6; P = 0.004), and antibiotic administration during the month preceding surgery (OR, 1.8; 95% CI, 1.5-7.8; P = 0.01). Conclusions: Although infection rate is low, there is a risk of ultrasound-guided catheter colonization that deserves careful monitoring of the insertion site in the postoperative period.

Background Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing ilioinguinal/iliohypogastric nerve (IHN) block with ultrasound-guided TAP block in patients undergoing inguinal hernia repair. Methods Two hundred and seventy-three patients undergoing day-case open inguinal hernia repair with a mesh were randomly allocated to receive either ultrasound-guided TAP block or blind IHN block with levobupivacaine 0.5%, before surgery. Patients were monitored for visual analogue scale (VAS) scores at rest (in the post-anaesthesia care unit, and at 4 and 12 h) and at rest and during movement (at 24, 48 h, 3 and 6 months). Pain at 6 months was also assessed using the DN4 questionnaire for neuropathic pain. Results Median VAS pain scores at rest were lower in the ultrasound-guided TAP group at 4 h (11 vs 15, P=0.04), at 12 h (20 vs 30, P=0.0014), and at 24 h (29 vs 33, P=0.013). Pain after the first 24 h, at 3 and 6 months after surgery, and DN4 scores were similar in both groups (P=NS). The proportion of patients with VAS >40 mm on movement at 6 months was comparable {18.2% [95% CI (12.2–26.1%)] vs 22.4% (15.8–30.6%) in the TAP and IHN groups, respectively, P=0.8}. Postoperative morphine requirements were lower during the first 24 h in the TAP block group (P=0.03). Conclusions Ultrasound-guided TAP block provided better pain control than ‘blind' IHN block after inguinal hernia repair but did not prevent the occurrence of chronic pain.

BACKGROUND AND OBJECTIVE Neurostimulation is commonly used to perform femoral nerve block. Ultrasound can be used to identify nerve structures and guide needle placement. The aim of this study was to compare postoperative analgesic efficiency when femoral nerve catheters were sited using ultrasound (in-plane approach) combined with neurostimulation or neurostimulation alone, for total knee arthroplasty. METHOD Ninety-three patients were enrolled in this prospective, randomized, blind study to receive a continuous femoral nerve block performed using conventional neurostimulation or ultrasound guidance combined with neurostimulation. The primary endpoint was the postoperative 48 h total local anaesthetic consumption. Other outcomes included visual analogue scale scores at rest, after 12, 24 and 48 h; total oral opioid dose; onset time of femoral block; procedural time; knee flexion and complications. Results are expressed with medians (25-75th percentiles), mean ± SD and n (%), as appropriate. RESULTS The onset time of sensory and motor block was faster in the ultrasound group [11 (6-17) min] than in the conventional group [16 (11-23) min, P = 0.009]. Total local anaesthetic dose was reduced [299 ± 45 vs. 333 ± 48 ml, (difference = 34.0 ml, 95% confidence interval 15.6-52.5 ml), P = 0.0003] and the time to the first analgesic request was lengthened [11 (7-13) vs. 7 (4-12) h, P = 0.034] in the ultrasound group. Visual analogue scale scores at 12, 24 and 48 h were lower in the ultrasound group as well as visual analogue scale scores during knee flexion at 48 h [14.5 (11.0-23.0) vs. 28.5 (21.0-43.5) mm, P < 0.0001]. Total oral morphine doses were 20 (0-40) vs. 40 (20-60) mg (P = 0.0065). Durations of hospital stay were comparable in both groups. CONCLUSION Continuous perineural femoral catheter placement using ultrasound combined with neurostimulation and an in-plane approach reduces total doses of local anaesthetic, morphine consumption and improves postoperative pain management by comparison with neurostimulation alone.

Resume L’abord de l’espace peridural thoracique est different du niveau lombaire en raison de l’inclinaison des apophyses epineuses qui varie de 25° a 45° de T4 a T10. Le volume de l’espace est inferieur au niveau thoracique. L’espace peut etre compartimente au niveau posterieur. La pression est plus negative au niveau thoracique haut. L’espace peut etre identifie par la technique de la goutte pendante ou par celle du mandrin liquide. Les consequences hemodynamiques (bradycardie et hypotension, baisse de l’inotropisme ventriculaire) de l’injection d’anesthesique local sont limitees si le bloc anesthesique est peu etendu et suspendu ; elles peuvent etre plus importantes pour des injections thoraciques basses plus etendues qui impliquent le systeme sympathique mesenterique (sequestration veineuse mesenterique). L’anesthesie peridurale thoracique ameliore la balance en oxygene du myocarde ischemique. L’administration peridurale thoracique d’anesthesique local ameliore la mecanique respiratoire en postoperatoire de chirurgie thoraco-abdominale et raccourcit la duree de l’ileus postoperatoire. L’association d’un anesthesique local a un opiace liposoluble en perfusion continue assure une analgesie de qualite.

Resume Introduction La survenue d’une dysfonction renale postoperatoire (DRPO) est bien documentee au cours de la chirurgie cardiovasculaire mais peu de donnees sont disponibles concernant les arthroplasties totales de hanche (ATH) qui s’adresse a des patients souvent porteurs de comorbidites susceptibles d’aggraver la fonction renale. Le but de cette etude prospective etait de determiner l’incidence de DRPO et ses facteurs predictifs apres ATH. Patients et methodes Ont ete inclus 755 patients operes dans un seul centre sur une duree de 14 mois. Trente et une variables demographiques, cliniques et biologiques ont ete repertoriees pour chaque patient. La DRPO a ete definie par un debit de filtration glomerulaire (DFG) evalue, selon la formule de Cockroft et Gault, inferieur ou egal a 60 ml/min par 1,73 m2 au septieme jour postoperatoire. Les facteurs predictifs ont ete determines par analyse univariee puis multivariee selon un modele de regression lineaire. Resultats En preoperatoire, 22,4 % des patients avaient un DFG inferieur ou egal a 60 ml/min par 1,73 m2. L’incidence de DRPO etait de 32,7 % a j3 et de 31,4 % a j7. Les facteurs de risque identifies de DRPO a j7 en analyse univariee etaient : l’âge, le score ASA, le diabete, l’HTA, l’utilisation de diuretique comme antihypertenseur, l’utilisation postoperatoire d’AINS, l’anemie, l’elevation preoperatoire de creatinine et d’uree sanguine. L’analyse multivariee retrouvait comme elements predictifs de DRPO un DFG preoperatoire inferieur ou egal a 60 ml/min par 1,73 m2 (OR : 5,8 ; IC 95 % [1,6–8,1], p = 0,0006), une duree de prescription d’AINS superieure ou egale a cinq jours (3,2 [1,4–7,1], p = 0,02), une uree preoperatoire superieure ou egale a 7,49 mmol/l (2,1 [1,4–11,1], p = 0,04) et l’âge superieur ou egal a 70 ans (1,8 [1,1–4,3], p = 0,02). Conclusion L’alteration de la fonction renale est frequente chez les patients qui beneficient d’une ATH. L’existence de comorbidites chez des patients de plus en plus âges et presentant des alterations quelques fois meconnues de leur fonction renale incite a les identifier precocement et a reduire la duree de prescription des AINS.

The effects of nefopam and ketamine on pain control and rehabilitation after total knee replacement were compared in a prospective, double blinded study. Seventy-five patients were randomly assigned to receive a 0.2mg kg(-1) bolus of nefopam or ketamine, followed by a 120microg kg(-1) h(-1) continuous infusion until the end of surgery, and 60microg kg(-1) h(-1) until the second postoperative day, or an equal volume of saline considered as placebo. Pain scores measured on a visual analog scale at rest and on mobilization, and patient-controlled intravenous morphine consumption, were assessed during 48h. We measured the maximal knee flexion on the third postoperative day, and the delay to obtain a 90 degrees flexion. Ketamine and nefopam reduced morphine consumption (p

Introduction La mise sur le marche en 2013 de la chloroprocaine (CP), anesthesique local de courte duree d’action pour la rachianesthesie participe a la generalisation de cette pratique en ambulatoire. L’objectif de l’etude CLOCK etait d’evaluer, l’impact de ce nouvel agent sur la qualite de la rachianesthesie et son adaptation au contexte de l’ambulatoire. Materiel et methodes Etude observationnelle, prospective, multicentrique, realisee aupres de patients adultes programmes pour une chirurgie ambulatoire de courte duree sous rachianesthesie avec la CP. Objectif principal : decrire les caracteristiques du bloc anesthesique obtenu avec cette technique. Objectifs secondaires : tolerance et adaptation a la pratique clinique de la technique. Resultats Trente-trois anesthesistes, exercant en etablissement prive (58 %), public (26 %) ou ESPIC (16 %), ont inclus 615 patients entre mai 2014 et janvier 2015. L’âge moyen etait de 47,2 ± 15,2 ans, l’IMC moyen de 25,6 ± 4,7 kg/m 2 . Les patients avaient en majorite un score ASA I (64 %) ou II (32 %). La repartition hommes/femmes etait de : 56 %/44 %. Les principaux actes operatoires etaient orthopediques (63 %), gynecologiques (16 %), urologiques (7 %) et digestifs (5 %). Les donnees necessaires a l’evaluation du critere principal etaient disponibles pour 580/615 patients (94,3 %). Les doses de CP administrees etaient de 50 mg (59 %) et 40 mg (32 %) pour des durees d’interventions de 26,7 ± 17,6 min. Une anesthesie complementaire peroperatoire a ete necessaire pour 36/580 patients (6,2 %), soit un taux de succes de 93,8 % des patients. Le niveau maximal du bloc sensitif etait en mediane a T10 [T1–T12]. L’eligibilite a la sortie de l’hopital a ete obtenue apres 252,7 ± 82,7 min, les autres caracteristiques figurent dans le Tableau 1 . Cinq cent quatre-vingt-dix-neuf effets indesirables (EI) ont ete decrits. Il s’agissait de douleur au site d’incision (25 %) et d’injection (12 %), lombalgie (9,4 %), hypotension (8,1 %), nausees (7,2 %), cephalees (6,8 %). Tous les EI etaient d’intensite faible a moderee, avec aucun cas de retention urinaire, ni de cas de TNS. Apres H24, 96 % des patients ont declare etre satisfaits de l’anesthesie. Discussion Une rachianesthesie realisee avec la CP a la dose de 40–50 mg est adaptee dans 94 % des cas a une chirurgie de courte duree avec un delai moyen d’eligibilite a la sortie d’un peu plus de 4 heures, sans risque de retention urinaire ou de TNS dans ce collectif. L’utilisation de la CP en rachianesthesie semble adaptee a la prise en charge ambulatoire des patients.

Bei der Entstehung chronischer Schmerzen nach einer Operation soll eine zentrale Sensibilisierung mit der Ausbildung einer Hyperalgesie eine wesentliche Rolle spielen. Dementsprechend konnten Medikamente, die diese Hyperalgesie verhindern, auch eine Praventionsmasnahme fur chronischen postoperativen Schmerz sein. Langzeitdaten dazu stellt nun eine franzosische Gruppe vor.

Background Ketamine, a N -methyl- d -aspartate receptor antagonist, may reduce postoperative opioid demand and improve postoperative analgesia. Methods Sixty-nine patients scheduled for lumbar disk surgery under general anaesthesia were enrolled in a randomised, double-blind study comparing three analgesic combinations that were started before surgical incision: morphine 0.1 mg kg −1 alone (group M; n = 23); ketamine 0.15 mg kg −1 alone (group K; n = 22); and a combination of morphine 0.1 mg kg −1 with ketamine 0.15 mg kg −1 (group KM; n = 23). Postoperatively patient-controlled analgesia was provided with intravenous morphine. Morphine consumption was assessed during 24 H, and pain scores were measured using a visual analogue scale (VAS) at rest and on mobilisation, during the first two postoperative days. Results In group KM, less i.v. morphine was administered in the post anaesthesia care unit than in group M (median [range]: 0 mg [0–2] vs. 7 mg [6–9], P = 0.009). Cumulative 24 H morphine consumption was reduced by 57% in group KM vs. group M, and by 48% in group KM vs. group K. Postoperative VAS scores were lower in group KM vs. groups K and M. Maximal VAS score on mobilization was reduced in group KM compared to groups K and M (38 mm [35–45] vs. 52 mm [48–59] and vs. 59 mm [55–64], in groups KM, K and M, respectively, P = 0.05 and P = 0.002). The incidence of postoperative nausea and vomiting was decreased in group KM compared to group M (21.7% vs. 43.5%, P = 0.001). Conclusion Ketamine small-dose, combined with morphine improves postoperative analgesia and reduces opioid-related side effects in lumbar disk surgery.