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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. ©

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 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.

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 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

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.