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The aim of this systematic review was to develop recommendations for the management of postoperative pain after primary elective total hip arthroplasty, updating the previous procedure-specific postoperative pain management (PROSPECT) guidelines published in 2005 and updated in July 2010. Randomised controlled trials and meta-analyses published between July 2010 and December 2019 assessing postoperative pain using analgesic, anaesthetic, surgical or other interventions were identified from MEDLINE, Embase and Cochrane databases. Five hundred and twenty studies were initially identified, of which 108 randomised trials and 21 meta-analyses met the inclusion criteria. Peri-operative interventions that improved postoperative pain include: paracetamol; cyclo-oxygenase-2-selective inhibitors; non-steroidal anti-inflammatory drugs; and intravenous dexamethasone. In addition, peripheral nerve blocks (femoral nerve block; lumbar plexus block; fascia iliaca block), single-shot local infiltration analgesia, intrathecal morphine and epidural analgesia also improved pain. Limited or inconsistent evidence was found for all other approaches evaluated. Surgical and anaesthetic techniques appear to have a minor impact on postoperative pain, and thus their choice should be based on criteria other than pain. In summary, the analgesic regimen for total hip arthroplasty should include pre-operative or intra-operative paracetamol and cyclo-oxygenase-2-selective inhibitors or non-steroidal anti-inflammatory drugs, continued postoperatively with opioids used as rescue analgesics. In addition, intra-operative intravenous dexamethasone 8-10 mg is recommended. Regional analgesic techniques such as fascia iliaca block or local infiltration analgesia are recommended, especially if there are contra-indications to basic analgesics and/or in patients with high expected postoperative pain. Epidural analgesia, femoral nerve block, lumbar plexus block and gabapentinoid administration are not recommended as the adverse effects outweigh the benefits. Although intrathecal morphine 0.1 mg can be used, the PROSPECT group emphasises the risks and side-effects associated with its use and provides evidence that adequate analgesia may be achieved with basic analgesics and regional techniques without intrathecal morphine. ispartof: ANAESTHESIA vol:76 issue:8 pages:1082-1097 ispartof: location:England status: published

International audience; The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy. Optimal pain management is known to influence postoperative recovery, but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative day. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery. We performed a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) with PROcedure SPECific Postoperative Pain ManagemenT (PROSPECT) methodology. Randomised controlled trials (RCTs) published in the English language, from January 2015 until March 2020, assessing postoperative pain, using analgesic, anaesthetic and surgical interventions, were identified from MEDLINE, EMBASE and Cochrane Databases. Of the 1797 studies identified, 35 RCTs and 3 meta-analyses met our inclusion criteria. NSAIDs and COX-2 selective inhibitors proved to lower postoperative pain scores. Continuous intravenous lidocaine reduced postoperative pain scores during open surgery. Local wound infiltration showed positive results in open surgery. Bilateral transversus abdominis plane (TAP) block was performed at the end of surgery and lowered pain scores in robot-assisted procedures, but results were conflicting for open procedures. Basic analgesia for prostatic surgery should include paracetamol and NSAIDs or COX-2 selective inhibitors. TAP block should be recommended as the first-choice regional analgesic technique for laparoscopic/robotic radical prostatectomy. Intravenous lidocaine should be considered for open surgeries.

Summary Tonsillectomy is one of the most frequently performed surgical procedures; however, pain management remains challenging. Procedure‐specific efficacy as well as specific risks of treatment options should guide selection of pain management protocols based on evidence and should optimise analgesia without harm. The aims of this systematic review were to evaluate the available literature and develop recommendations for optimal pain management after tonsillectomy. A systematic review utilising preferred reporting items for systematic reviews and meta‐analysis guidelines with procedure‐specific postoperative pain management (PROSPECT) methodology was undertaken. Randomised controlled trials published in the English language up to November 2019 assessing postoperative pain using analgesic, anaesthetic or surgical interventions were identified. Out of the 719 potentially eligible studies identified, 226 randomised controlled trials met the inclusion criteria, excluding the studies examining surgical techniques. Pre‐operative and intra‐operative interventions that improved postoperative pain were paracetamol; non‐steroidal anti‐inflammatory drugs; intravenous dexamethasone; ketamine (only assessed in children); gabapentinoids; dexmedetomidine; honey; and acupuncture. Inconsistent evidence was found for local anaesthetic infiltration; antibiotics; and magnesium sulphate. Limited evidence was found for clonidine. The analgesic regimen for tonsillectomy should include paracetamol; non‐steroidal anti‐inflammatory drugs; and intravenous dexamethasone, with opioids as rescue analgesics. Analgesic adjuncts such as intra‐operative and postoperative acupuncture as well as postoperative honey are also recommended. Ketamine (only for children); dexmedetomidine; or gabapentinoids may be considered when some of the first‐line analgesics are contra‐indicated. Further randomised controlled trials are required to define risk and combination of drugs most effective for postoperative pain relief after tonsillectomy.

Introduction Postoperative ileus(POI) and anastomotic leakage(AL) are highly associated but the direction of this link is unknown. Indeed, it has traditionally been stated that AL leads to POI(secondary POI). The objective was to statistically determine the best model of link between POI and AL by comparing different Structural Equation Models(SEM). Methods This is a retrospective analysis of a prospective multicentric database from the Francophone Group for Enhanced Recovery after surgery(GRACE) including patients undergoing colorectal resection or Hartmann reversal between 2014 and 2017. The main outcome measure was the occurrence of postoperative ileus defined by the absence of Gastrointestinal (GI)-3 recovery in or after postoperative day 4 and the occurrence of AL. Results Among the 2227 patients included, 223 patients experienced POI (10 %) and 72 patients experienced anastomotic leakage (3.2 %). In all the models, POI was significantly increased in case of male gender, older age, opioids consumption, right colectomy, chronic obstructive bronchopneumopathy disease and performance of a stoma, and reduced by Enhanced Recovery Programs (ERP) compliance ≥ 70 % and intake of Non-Steroidal Anti-Inflammatory Drugs. Open surgery was not significantly associated with POI in all the models. In contrast, the male gender was the only factor increasing AL in the model drawn with ERP risk factors for AL. In all the models, POI was highly associated with AL and statistical analyses advocate for POI leading to AL. Conclusion The findings of the present large study suggest that the more statistically probable model is the one in which POI come first before AL.

Nonsteroidal anti-inflammatory drugs (NSAID) play an important role in the treatment of postoperative pain, particularly in the context of enhanced recovery after colorectal surgery. Several recent articles have suggested that NSAID may have a deleterious effect on colo-colic or colorectal anastomoses. The aim of this review is to analyze the evidence based on meta-analyses and cohort studies in the literature. A systematic review of clinical studies identified 12 studies including two meta-analyses and ten comparative cohort studies that included a large number of patients. The data in these studies are heterogeneous, often biased, and do not permit a formal recommendation based on a high level of evidence. The main conclusion of this review is that the balance of benefit vs. risk (analgesic effect/risk of anastomotic disruption) is acceptable; it appears (with a low level of evidence) that a prescription of NSAID for 48 hours after surgery may be recommended for elective colon surgery. Nevertheless, it is important to respect the specific contra-indications of NSAID and avoid postoperative NSAID use if there are risk factors for anastomotic leakage: advanced age, malnutrition, severe comorbidities, intraoperative difficulties. © 2016 Elsevier Masson SAS

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient’s blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety. 2013 Published by Elsevier Masson SAS.

International audience; BACKGROUND: Morphine, and analgesics other than morphine (AOM), are commonly used to treat postoperative pain after major surgery. However, which AOM provides the best efficacy-safety profile remains unclear. METHODS: Randomized trials of any AOM alone or any combination of AOM compared with placebo or another AOM in adults undergoing major surgery and receiving morphine patient-controlled analgesia were included in a network meta-analysis. The outcomes were morphine consumption, pain, incidence of nausea, vomiting at 24 h and severe adverse effects. RESULTS: 135 trials (13,287 patients) assessing 14 AOM alone or in combination were included. For all outcomes, comparisons with placebo were over-represented. Few trials assessed combinations of two AOM and none the combination of three or more. Network meta-analysis found morphine consumption reduction was greatest with the combination of two AOM (acetaminophen + nefopam, acetaminophen + NSAID, and tramadol + metamizol): -23.9 (95% CI -40;-7.7), -22.8 (-31.5;-14) and -19.8 (35.4;-4.2) mg per 24 h, respectively. For AOM used alone, morphine consumption reduction was greatest with α-2 agonists, NSAIDs, and COX-2 inhibitors. When considering the risk of nausea, NSAIDs, corticosteroids and α-2 agonists used alone were the most efficacious (OR 0.7 [95% CI: 0.6-0.8], 0.36 [0.18-0.79], 0.41 [0.15-.64], respectively). The paucity of severe adverse effects data did not allow assessment of efficacy-safety balance. CONCLUSIONS: A combination of aetaminophen with either an NSAID or nefopam was superior to most AOM used alone, in reducing morphine consumption. Efficacy was best with three AOM used alone (α-2 agonists, NSAIDs and COX-2 inhibitors) and least with tramadol and acetaminophen. There is insufficient trial data reporting adverse events. CLINICAL TRIAL REGISTRATION: PROSPERO: CRD42013003912.

International audience; Nonsteroidal anti-inflammatory drugs (NSAID) play an important role in the treatment of post-operative pain, particularly in the context of enhanced recovery after colorectal surgery. Several recent articles have suggested that NSAID may have a deleterious effect on colo-colic or colo-rectal anastomoses. The aim of this review is to analyze the evidence based on meta-analyses and cohort studies in the literature. A systematic review of clinical studies identified twelve studies including two meta-analyses and ten comparative cohort studies that included a large number of patients. The data in these studies are heterogeneous, often biased, and do not permit a formal recommendation based on a high level of evidence. The main conclusion of this review is that the balance of benefit vs. risk (analgesic effect/risk of anastomotic disruption) is acceptable; it appears (with a low level of evidence) that a prescription of NSAID for 48 h after surgery may be recommended for elective colon surgery. Nevertheless, it is important to respect the specific contra-indications of NSAID and avoid post-operative NSAID use if there are risk factors for anastomotic leakage: advanced age, malnutrition, severe co-morbidities, intra-operative difficulties. (C) 2016 Elsevier Masson SAS. All rights reserved.

Since the revolution of ultrasound in regional anesthesia, new techniques have arisen. The "transversus abdominis plane" block or TAP block is one of them. The benefits of a TAP block for postoperative analgesia have been shown mostly after laparotomy. Because this block seems to be technically easy, many anesthesiologists have quickly adopted it. However, the TAP block presents some technical specificities and knowledge of the anatomy is required. This article reviews the anatomy of the abdominal wall, the different blocks, the indications, the complications, and highlights the many unanswered questions left. This review proposes a new vision of the abdominal wall blocks based on a new understanding of the anatomy of the abdominal wall associated with an ultrasound technique.

Resume Objectif 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. Type d’etude Retrospective, observationnelle. Patients L’ensemble des patients adultes ayant beneficie d’une intervention programmee dans sept specialites chirurgicales. Methodes L’ensemble des examens preoperatoires prescrits pendant une semaine (2008) a ete note. Une grille d’aide a la prescription etablie a partir des recommandations publiees et validee par les anesthesistes-reanimateurs de l’etablissement a ensuite ete mise en place. Un second audit a ete realise un an apres (2009). Resultats En 2008, 85 dossiers ont ete analyses et 79 en 2009. En moyenne, la moitie (46 % en 2008 et 58 % en 2009) des prescriptions n’etaient pas conformes aux recommandations, les praticiens prescrivant plus que ce qu’ils avaient eux-memes recommande. La conformite globale aux recommandations locales n’a pas significativement evolue en 2009. Cependant, les prescriptions d’electrocardiogramme (ECG) (79 % versus 95 % ; p Conclusion Le nombre et le cout des prescriptions d’examens complementaires ne suivant par les recommandations sont importants. L’amelioration des prescriptions apres mise en place de recommandations locales decoulant d’un referentiel national n’est ni immediate ni complete.

Gli anestetici locali (AL) sono agenti che bloccano in modo reversibile la conduzione nervosa. Sono aminoamidi o aminoesteri. In termini di farmacocinetica sono basi deboli che si legano ai componenti del sangue: emazie e proteine sieriche. Le concentrazioni di AL sono particolarmente elevate nel sito d’azione poiche sono somministrati localmente. La durata d’azione degli AL dipende dalla velocita del loro riassorbimento sistemico. Gli esteri sono idrolizzati nel siero e le emazie da esterasi non specifiche. Dopo il loro passaggio nella corrente sanguigna gli AL amidi sono eliminati dal fegato attraverso il sistema del citocromo P450. Gli AL sono utilizzati per la loro capacita di bloccare la trasmissione dell’influsso nervoso lungo la membrana lipidica assonale. Essi agiscono ostruendo il poro centrale del canale del sodio, al quale accedono attraverso il versate citoplasmatico. La loro azione non e limitata ai soli canali del sodio: gli AL hanno un effetto sui canali del potassio e del calcio. Gli AL hanno inoltre proprieta antinfiammatorie intrinseche e possono modulare la risposta infiammatoria. Inoltre, un blocco nervoso permette di attenuare lo sviluppo della sensibilizzazione del sistema nervoso secondaria a un’aggressione tissutale (come un intervento chirurgico) e responsabile dei fenomeni di iperalgesia, riducendo cosi anche la morbilita postoperatoria e accelerando la riabilitazione. Gli AL hanno un effetto su una grande varieta di processi cellulari tra cui, in particolare, le prostaglandine implicate nell’infiammazione, le mitogen-activated protein kinase (MAPK) che svolgono un ruolo fondamentale nella trasduzione del segnale dalla superficie della cellula fino al nucleo e nel mantenimento del segnale dopo l’infiammazione, i recettori associati alle proteine G che intervengono nella comunicazione intra- e intercellulare e i recettori N-metil-D-aspartato (NMDA) fattore chiave dello sviluppo dell’iperalgesia perioperatoria. Gli AL alterano anche il metabolismo energetico, il che potrebbe spiegare la loro miotossicita. In termini di tossicita, la maggior parte degli anestetici e innanzitutto tossica a livello del sistema nervoso centrale e poi, a una concentrazione piu alta, diventa cardiotossica. Gli AL riducono la conduzione intraventricolare e prolungano il periodo refrattario. Essi hanno, inoltre, una tossicita propria per la fibra nervosa che puo provocare disturbi neurologici transitori. Gli enantiomeri S, come la ropivacaina e la levobupivacaina, benche non mettano al riparo da accidenti cardiaci, sembrano permettere una rianimazione molto piu efficace. Questa rianimazione e stata recentemente rivoluzionata dalle pubblicazioni che mostrano l’interesse della perfusione di un’emulsione lipidica fin dalla comparsa di segni cardiaci o nervosi di tossicita. E oggi formalmente raccomandato di disporre di flaconi di emulsione intralipidica nella struttura in cui si pratica un’anestesia locoregionale.

Los anestesicos locales (AL) son agentes que bloquean de forma reversible la conduccion nerviosa. Se trata de aminoamidas o de aminoesteres. En terminos de farmacocinetica, son bases debiles que se fijan a los componentes de la sangre: eritrocitos y proteinas sericas. Puesto que se administran de forma local, las concentraciones de AL son particularmente elevadas en el sitio de accion. La duracion de accion de los AL depende de la velocidad de su reabsorcion sistemica. Los esteres son hidrolizados en el suero y los eritrocitos, por esterasas inespecificas. Tras pasar a la corriente sanguinea, los AL amidas son metabolizados en el higado por el sistema del citocromo P450. Los AL se usan por su capacidad para bloquear la transmision del impulso nervioso a lo largo de la membrana lipidica axonal. Actuan por obstruccion del poro central del canal de sodio, al que llegan por la cara citoplasmatica. Su accion no se limita a los canales de sodio: los AL tambien actuan en los canales de potasio y de calcio. Los AL tienen propiedades antiinflamatorias intrinsecas y pueden modular la respuesta inflamatoria. Ademas, un bloqueo nervioso atenua la sensibilizacion del sistema nervioso secundaria a una agresion tisular (por ejemplo, una intervencion quirurgica) y causante de hiperalgesia, lo cual reduce la morbilidad postoperatoria y acelera la rehabilitacion. Los AL influyen en numerosos procesos celulares, sobre todo respecto a las prostaglandinas implicadas en la inflamacion, las proteinas cinasas activadas por mitogenos (MAPK) que cumplen una funcion principal en la transduccion de la senal de la superficie de la celula hasta el nucleo y el mantenimiento de la senal tras la inflamacion, los receptores acoplados a las proteinas G que actuan en la comunicacion intra e intercelular y los receptores del N-metil-D-aspartato (NMDA), factor fundamental del desarrollo de la hiperalgesia perioperatoria. Los AL tambien alteran el metabolismo energetico, lo que podria explicar su miotoxicidad. En terminos de toxicidad, la mayoria de los anestesicos son inicialmente toxicos en el sistema nervioso central y despues, a mayor concentracion, se tornan cardiotoxicos. Los AL reducen la conduccion intraventricular y prolongan el periodo refractario. Ademas, provocan una toxicidad directa sobre la fibra nerviosa, lo cual puede ocasionar trastornos neurologicos transitorios. Los enantiomeros S, como la ropivacaina y la levobupivacaina, si bien no protegen de los accidentes cardiacos, al parecer permitirian una reanimacion mucho mas eficaz. Esta reanimacion ha sido modificada hace poco a partir de publicaciones relativas al interes de la perfusion de una emulsion lipidica en el momento en que aparecen los signos cardiacos o nerviosos de toxicidad. Hoy se recomienda formalmente tener a mano frascos de emulsion grasa cuando se administra una anestesia locorregional.

International audience; Recent advances in the management of peri-operative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain pre-operatively, pre-operative opioid use, and the intensity of post-operative pain. Ideal management of peri-operative pain in 2015 aims to optimize postoperative pain management, to detect the risk of pain chronicity begins pre-operatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in post-operative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer [1], and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intra-operative and post-operative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications. (C) 2016 Published by Elsevier Masson SAS.

National audience; Introduction Le dépôt de sang du déchocage du CHU de Rennes est un dépôt d’urgence où seule l’urgence vitale justifie l’utilisation des produits sanguins labiles (PSL) stockés. L’objectif de cette évaluation des pratiques professionnelles était de caractériser les PSL délivrés par ce dépôt en 2013 ainsi que la population transfusée. La pertinence d’utilisation de ces PSL a également été analysée. Patients et méthode Deux groupes d’experts, cliniciens et hémovigilant, ont évalué la pertinence d’utilisation des PSL du dépôt à partir de critères cliniques, biologiques et des délais de transfusion. Résultats Cent vingt-deux PSL (112 CGR et 10 PFC) ont été transfusés à 49 patients, d’âge moyen 55 ans, majoritairement de sexe masculin (69 %). Les indications principales étaient le polytraumatisme et l’hémorragie digestive. Lors de la décision transfusionnelle, l’Hemocue moyen était de 7,7 ± 2,4 g.dL−1 et 85 % des patients présentaient des signes de choc (Tableau 1). Le taux de mortalité (25 %) et le nombre moyen de PSL transfusés dans les 24 heures (10 CGR, 10 PFC et 2 CP) témoignaient de la gravité des patients. Le délai moyen entre l’admission du patient et la transfusion du premier PSL du dépôt était de 61 minutes. Pour 62 % des patients, l’hémoglobinémie post-transfusionnelle était > à 10 g.dL−1. L’utilisation des PSL était pertinente dans 75 % des cas mais le choix du phénotype Rhésus des CGR n’était pertinent que dans 35 % des cas. Conclusion Le nombre important de transfusions par excès nécessite la mise en place d’un programme d’optimisation de la quantité de CGR transfusés par patient. Une sensibilisation des prescripteurs sur la ressource précieuse en CGR O RH-1 est nécessaire

Introduction The cerebral protective effect of xenon anesthesia could be of interest during carotid surgery. The purpose of this study was to compare the effects of xenon on cerebral oxygen saturation with those of propofol during carotid clamping. Methods After approval of Research Ethics Board and patient informed consent, 74 patients scheduled for carotid endarterectomy were enrolled. Patients were not randomized but were well matched by preoperative characteristics. Patients in the Xenon group were the ones scheduled for surgery in the operative theater equipped with the xenon anesthesia system. Anesthesia was started with a target control infusion of propofol and remifentanil. Patients were then divided into the control group (37 patients) with anesthesia maintained with target control infusion propofol and remifentanil and the Xenon group with anesthesia maintained with xenon (target inspired concentration of 60%) and target control infusion remifentanil. Remifentanil and xenon or propofol were stopped at the end of skin closure. Results A cerebral oxygen saturation decrease below 55% was less frequently observed in the Xenon group during carotid cross-clamping (7/37 patients vs 15/37; p=0.01). Compared with values observed before clamping, the decrease in cerebral oxygen saturation during clamping was significantly less important in the Xenon group (12±11% vs 17±14%, p=0.04). Blood pressure and heart rate were not different between groups during carotid clamping. Conclusions This pilot study suggests that xenon anesthesia may be associated to higher cerebral oxygen saturation values when compared to propofol anesthesia during cross-clamping for carotid endarterectomy.

Chronic pain is usually underestimated in children, due to lack of knowledge and its specific signs. In addition to suffering, chronic pain causes a physical, psychological, emotional, social, and financial burden for the child and his family. Practitioners may find themselves in a situation of failure with depletion of medical resources. Some types of chronic pain are refractory to conventional systemic treatment and may require the use of regional anesthesia. Cancer pain is common in children and its medical management is sometimes insufficient. It is accessible to neuroaxial or peripheral techniques of regional anesthesia if it is limited to an area accessible to one of these techniques and no contraindications (e.g., thrombopenia) are present. Complex regional pain syndrome 1 is not rare in children and adolescents, but it often goes undiagnosed. Regional anesthesia may contribute to the treatment of complex regional pain syndrome 1, mainly in case of recurrence, because it provides rapid effective analgesia and allows rapid implementation of intensive physiotherapy. These techniques have also shown interest in phantom limb pain after limb amputation, but they remain controversial for erythromelalgia pain or chronic abdominopelvic pain. Finally, the treatment of postdural puncture headache due to cerebrospinal fluid leak can be treated by performing an epidural injection of the patient's blood, called a blood-patch. Finally, the management of children with chronic pain should be multidisciplinary (pediatrician, physiotherapist, psychologist, surgeon, anesthesiologist) to support the child and her problem in its entirety.

Surgical treatment of cancer is usually necessary but it can paradoxically aggravate the patient outcome by increasing the risk of recurrence. Many perioperative factors have been shown to contribute to the dissemination of the tumor: surgery itself, stress, inflammation, pain, anaesthetic drugs, blood transfusion, etc. The type of anaesthesia chosen in the cancer patient could then be crucial and influence the evolution of the disease. Experimental, preclinical and retrospective studies have suggested that a regional anesthesia associated or not with a general anesthesia for carcinologic surgery might reduce the risk of cancer recurrence. This text reviews the factors promoting the recurrence of tumors after carcinologic surgery and the potential possibilities of protection associated with the type of anaesthesia chosen.

to compare the number and the cost of preoperative tests ordered before scheduled surgery before and after implementation of local guidelines.observational retrospective survey.All patients scheduled in seven surgical specialties.all preoperative tests ordered during a 1-week period (2008) were noted. Local guidelines based on published guidelines and validated by anesthesiologists of the hospital were then implemented. A second audit was performed 1 year after (2009).Eighty-five and 79 patients' files were analyzed in 2008 and 2009, respectively. On average, half (46% in 2008 and 58% in 2009) of prescriptions did not follow the guidelines, with anaesthesiologists prescribing more than their own recommendations. Overall conformity to the local guidelines did not improve between 2008 and 2009. However, EKG (79% vs. 95%, p0.05) and serum electrolytes (72% vs. 99%, p0.05) ordered were significantly in better agreement with the guidelines. Costs associated with inadequate orders were divided by 2.4 in 2009.existing practice is overall poor. Non-compliance of preoperative testing to guidelines is a significant cause of uncontrolled cost. Change in compliance is a slow process.

Since the revolution of ultrasound in regional anesthesia, new techniques have arisen. The "transversus abdominis plane" block or TAP block is one of them. The benefits of a TAP block for postoperative analgesia have been shown mostly after laparotomy. Because this block seems to be technically easy, many anesthesiologists have quickly adopted it. However, the TAP block presents some technical specificities and knowledge of the anatomy is required. This article reviews the anatomy of the abdominal wall, the different blocks, the indications, the complications, and highlights the many unanswered questions left. This review proposes a new vision of the abdominal wall blocks based on a new understanding of the anatomy of the abdominal wall associated with an ultrasound technique.

Current knowledge suggests that peripheral inflammation following surgery activates and sensitizes both peripheral and central nervous system. These phenomena involved in the maintenance of the inflammatory response lead to hypersensibility, hyperalgesia and allodynia. Hyperalgesia participates in the general experience of postoperative pain and ALo in the development of chronic pain. A correlation between the ability of treatments to reduce areas of hypersensitivity surrounding the wound after surgery and their ability to reduce the incidence of chronic pain has been shown. For a long time, local anaesthetics have been used for their capacity to block nociceptive input. They can ALo modulate the inflammatory response following a surgical trauma. By inhibiting the nervous conductivity at the site of the trauma, local anesthetics attenuate the sensitization of the nervous system and therefore the inflammatory phenomena. They ALo exert intrinsic anti-inflammatory properties by modulating the local and systemic liberation of inflammatory mediators. The mechanisms involved are not clearly elucidated. Local, systemic, and spinal inflammatory mechanisms may be influenced by local anesthetics through multiple different mechanisms. The therapeutic implications of effects of local anesthetics on local, systemic, and spinal inflammatory responses merit further study.

Background There is considerable variability in the inter-patient response to norepinephrine. Pharmacokinetic studies of dopamine infusion in volunteers and in patients have also shown large variability. The purpose of this study was to define the pharmacokinetics of norepinephrine in septic shock and trauma patients. Methods After Ethical Committee approval and written informed family consent, 12 patients with septic shock and 11 trauma patients requiring norepinephrine infusion were studied. Norepinephrine dose was increased in three successive steps of 0.1 mg kg−1 min−1 at 15-min intervals (20% maximum allowed increase in arterial pressure). Arterial blood was sampled before and at 0.5, 13, and 15 min after each infusion rate change and 30 s, 1, 2, 5, 10, and 15 min after return to baseline dosing. Norepinephrine was assayed by HPLC. The pharmacokinetics were modelled using NONMEM (one-compartment model). The effects of group, body weight (BW), gender and SAPS II (Simplified Acute Physiology Score II) [Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. J Am Med Assoc 1993; 270: 2957–63] patients score on clearance (CL) and volume of distribution (V) were tested. Results Group, gender, and BW did not influence CL or V. CL was negatively related to SAPS II. CL and T1/2 varied from 3 litre min−1 and 2 min, respectively, when SAPS II=20 to 0.9 litre min−1 and 6.8 min when SAPS II=60. Conclusion In trauma patients and in septic shock patients, norepinephrine clearance is negatively related to SAPS II.

The aim of this study was to evaluate betablockers use and effect in the preoperative period in vascular and thoracic surgery.Retrospective study concerning patients scheduled for high or intermediate surgical risk procedure (n = 321) in a French vascular and thoracic surgery department during 2002. Eligibility for betablocker therapy was defined as previously described for inclusion criteria in Mangano's Study (N Engl J Med 1996;335:1713-20). Therapy effect was evaluated with heart rate in the operating room.Forty-six percent (99/213) of eligible patients for betablockers were really treated in the preoperative period. In patients treated with betablockers, 40% appeared in the operating room with the most favorable heart rate (55-65 b/min). During surgical procedure, heart rate over 80 b/min was observed in more than 30% of patients with betablocker therapy. In patients eligible for betablocker therapy but untreated with these drugs, only 12% have received betablockers in the preoperative period.Betablockers underuse is important in the preoperative period, and effect on heart rate is rarely optimal. This fact should encourage physicians to apply protocols for perioperative betablockers administration.

The occurrence of tension pneumopericardium in patient in spontaneous ventilation after blunt trauma is rare. The diagnosis is difficult and it may remain unrecognized. The authors reported the case of a 50 year-old trauma patient with a tension pneumothorax associated with a pneumopericardium. The patient was not mechanically ventilated at any time. Pericardial relief was obtained by insertion of a chest tube.

The pharmacokinetic properties of remifentanil may allow a rapid analgesic action during painful procedures and short lasting postoperative respiratory depression.We carried out a randomized, blind, study in 60 patients to compare remifentanil (continuous i.v. infusion starting at 0.025 micro g kg(-1) min(-1)) and sufentanil (i.v. doses of 0.15 micro g kg(-1)) during extra-corporeal shock wave lithotripsy (ESWL). Pain was assessed using a numerical pain scale (0-100), and pain relief was defined as a scoreor =30. Respiratory depression was defined as a ventilatory frequency less than10 breaths min(-1) on two occasions or a peripheral oxygen saturationor =92%, or administration of naloxone.The quality of analgesia was similar in both groups, during and after ESWL. During ESWL, there was no significant difference in respiratory depression in the remifentanil and sufentanil groups (53 vs 73%, NS). The percentage of satisfied patients (73 vs 83%, NS) and satisfied surgeons (97 vs 100%, NS) did not significantly differ between groups. After the procedure patients given remifentanil had less respiratory depression (20 vs 53%, P0.05) and less nausea and vomiting (3 vs 20%, P0.05).A continuous i.v. infusion of remifentanil provided comparable analgesia and caused less respiratory depression and nausea and vomiting than i.v. boluses of sufentanil in patients undergoing extra-corporeal shock wave lithotripsy.

Introduction Depuis la publication et la diffusion des proprietes anti-hyperalgesiques de la ketamine, ce medicament presente un regain d’interet [1] . En raison d’une utilisation croissante dans differentes indications, le comite douleur ALR (CD ALR) de la SFAR a realise une enquete concernant l’utilisation de ce medicament aupres des medecins anesthesistes-reanimateurs, des algologues et des urgentistes. Materiel et methodes Un questionnaire anonyme elabore et valide par le CD ALR a ete diffuse sur le site Internet de la SFAR, la SFETD et la SFMU pendant une periode de 3 mois. Les statistiques descriptives ont ete realisees a l’aide du logiciel Statview. Les donnees sont presentees en nombre (%) ou en mediane et quartile. Resultats A ce jour, 949 reponses ont ete analysees (SFAR et SFTED). Parmi les 740 praticiens membres de la SFAR, 717 (97 %) utilisent la ketamine, 40 % l’utilisent chez tous les patients et 24 % chez les patients âges de plus de 75 ans. La ketamine est majoritairement utilisee au bloc operatoire (95 %), sous anesthesie generale (71 %), 60 % en SSPI, 41 % en reanimation et 22 % en hospitalisation. En termes de surveillance, 73 % considerent que la conscience est l’element a surveiller lors de l’administration de ketamine, 47 % surveillent les parametres hemodynamiques et 20 % n’ont recours a aucune surveillance. L’indication principale est la prevention de l’hyperalgesie dans 96 % des cas. L’administration est dans 53 % des cas peroperatoire exclusive en bolus (97 %) suivi une fois sur deux d’une administration continue. La posologie du bolus est de 0,39 (0,15–0,4) mg.kg −1 . En postoperatoire, 12 % des praticiens poursuivent systematiquement l’administration continue IVSE (35 ± 16 heures), 29 % parfois et 25 % l’associent a la morphine dans la PCA. Cinquante-deux pour cent des praticiens prescrivent un bolus de ketamine en cas d’echec de titration morphinique (au-dela de 0,2 (0,15–0,25) mg.kg −1 de morphine) en SSPI. Parmi les adherents de la SFAR ayant repondu au questionnaire, 33 % utilisent la ketamine dans le cadre de la douleur chronique. Parmi eux, 66 % l’administre systematiquement en bolus et 63 % en continue. L’utilisation per os est marginale (3 %). Les effets secondaires consideres comme les plus genants sont les troubles psychodysleptiques (82 %) et les hallucinations (69 %). L’hypertension (16 %), la tachycardie (15 %), l’hypertension intracrânienne (15 %), la sedation (20 %) et les troubles de la vigilance (30 %) viennent en seconde ligne. Trente-quatre pour cent des praticiens utilisant la ketamine disposent d’un protocole institutionnel detaillant son utilisation et seuls 39 % connaissent l’existence de recommandations de la SFAR sur le sujet. Discussion Les premieres analyses de cette enquete sur l’utilisation de la ketamine mettent en evidence (a) une utilisation centree sur les proprietes antihyperalgesiques et (b) une disparite des pratiques. La prochaine mise a jour des recommandations sur la prise en charge de la douleur postoperatoire [2] devra integrer ces resultats et proposer un chapitre specifique et sur les modalites d’utilisation de la ketamine.

To review fresh frozen plasma (FFP) prescriptions and compare their validity to the legal french guidelines (law of the 12/03/91).Assessment of all prescriptions has been carried out by a multidisciplinary committee.All the adults transfused with FFP over one year in a teaching hospital.Following each head of department's agreement and following a written notice to all prescribers within the hospital to inform them of the undergoing study and its methodological validation by the board of quality experts, each delivery of FFP was followed by a questionnaire addressed to the prescriber. A board of experts then assessed the significance of the prescription in accordance with the legal requirements after reviewing each medical file.144 prescriptions to 89 patients were assessed: 23% were judged inappropriate by the experts and 6% did not respect the law. The inappropriate transfusions distribute as follows: intensive care patients (73% of which 80% in multiple organ failure (MOF) and 20% in haemorrhagic shock), cirrhotic patients (12%), patients treated with vitamin K antagonists (12%), obstetric patients (3%). Nine percent of the appropriate transfusions were judged in insufficient volume. The hospital mortality rate was 48%. Among prescribers, 59% were not aware of the law.A significant proportion of FFP transfusions is inappropriate. This study, which is the first step of a quality assurance program, will be followed by local recommendations for clinical practice. The current standards of prescribing FFP are more restrictive than those defined in the legal french guidelines.

Introduction In elderly patients, goal-directed haemodynamic therapy (GDHT), depth of anaesthesia monitoring and lung-protective ventilation have been shown to improve postoperative outcomes. The aim of this study was to evaluate current practices concerning strategies of anaesthesia optimisation in patients aged ≥ 75 years. Patients and methods A multicentre observational study was performed from February to May 2015 in 23 French academic centres. On 30 consecutive days in each centre, patients ≥ 75 years with at least one major comorbidity undergoing elective or emergency procedures (femoral-neck fractures surgery, intraperitoneal abdominal surgery or vascular surgery) were included. Patient characteristics and data related to GHDT, management of hypotension, monitoring of temperature and depth of anaesthesia, lung ventilation, point of care haemoglobin testing were collected. Results In total, 807 patients were included. Only 2% of patients [95% CI: 1–3] received GHDT in full accordance with guidelines. Depth of anaesthesia monitoring was largely performed (53% [95% CI: 50–56]). The multifaceted strategy of lung-protective ventilation combining low tidal volumes (6–8 mL/kg), PEEP of 5–8 cm cmH2O, and repeated recruitment manoeuvres, was performed in only 4% [95% CI: 3–5] of patients. A centre effect was a major determinant of variation concerning implementation of these strategies. Discussion In patients’ ≥ 75 years, strategies of anaesthesia optimisation are not in accordance with eligible guidelines. Implementation of these techniques varies independently of factors related to the patient or the type of surgery and may be dependent on the generated constraints.