Intrapandemic regional anesthesia as practice: a historical cohort study in patients undergoing breast cancer surgery.

BACKGROUND: The COVID-19 pandemic has markedly increased delays in oncologic surgeries because of the virus's impact on traditional anesthetic management. Novel protocols, developed to protect patients and medical professionals, have altered the ways and instances in which general anesthesia (GA) can be safely performed. To reduce virus exposure related to aerosol-generating procedures, it is now recommended to avoid GA when feasible and promote regional anesthesia instead. At our institution, we observed faster postoperative recovery in patients who received paravertebral blocks for breast cancer surgery instead of GA. This led us to formally evaluate whether regional anesthesia instead of GA helped improve time to hospital discharge. METHODS: We conducted a historical cohort study to retrospectively analyze two cohorts of patients: prepandemic vs intrapandemic. We obtained approval from our institutional ethics committee to review files of consecutive patients who underwent breast cancer surgery between 30 March 2020 and 30 June 2020 (intrapandemic group; N = 106) and consecutive patients-moving backwards-from 28 February 2020 to 6 December 2019 (prepandemic group; N = 104). The primary outcome was the length of time between the end of surgery to readiness for hospital discharge. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), the need for postoperative analgesia, and the duration of stay in the postanesthesia care unit (PACU). RESULTS: The median [interquartile range (IQR)] time to readiness for hospital discharge was significantly lower in patients who received paravertebral blocks for breast cancer surgery compared with GA (intrapandemic group, 119 [99-170] min vs prepandemic group, 191 [164-234] min; P < 0.001) as was the incidence of PONV (3% vs 11%; P = 0.03) and median [IQR] PACU durations of stay (29 [21-39] min vs 46 [37-63] min; P < 0.001). CONCLUSIONS: Patients who received paravertebral blocks for breast cancer surgery in the intrapandemic group were ready for hospital discharge earlier, spent less time in the PACU, and experienced less PONV than those who received GA in the prepandemic group. With growing surgical wait times, concerns related to aerosol-generating procedures, and recommendations to avoid GA when feasible, paravertebral blocks as the principal anesthetic modality for breast cancer surgery offered benefits for patients and medical teams.

RéSUMé: CONTEXTE: La pandémie de COVID-19 a considérablement augmenté les retards dans les chirurgies oncologiques en raison de l'impact du virus sur la prise en charge anesthésique traditionnelle. De nouveaux protocoles, mis au point pour protéger les patients et les professionnels de la santé, ont modifié les façons et les cas dans lesquels une anesthésie générale (AG) peut être réalisée en toute sécurité. Afin de réduire l'exposition au virus liée aux interventions génératrices d'aérosols, il est maintenant recommandé d'éviter l'AG lorsque possible et de privilégier l'anesthésie régionale. Dans notre établissement, nous avons observé une récupération postopératoire plus rapide chez les patientes ayant reçu des blocs paravertébraux pour une chirurgie de cancer du sein au lieu d'une AG. Cela nous a menés à évaluer de façon formelle si l'anesthésie régionale au lieu de l'AG avait contribué à réduire les délais jusqu'au congé de l'hôpital. MéTHODE: Nous avons réalisé une étude de cohorte historique afin d'analyser rétrospectivement deux cohortes de patientes : prépandémie vs intrapandémie. Nous avons obtenu l'approbation de notre comité d'éthique institutionnel pour examiner les dossiers de patientes consécutives ayant bénéficié d'une chirurgie de cancer du sein entre le 30 mars 2020 et le 30 juin 2020 (groupe intrapandémie; n = 106) et des patientes consécutives ­ en reculant ­ du 28 février 2020 au 6 décembre 2019 (groupe prépandémie; n = 104). Le critère d'évaluation principal était le délai entre la fin de la chirurgie et le moment où les patientes étaient prêtes à recevoir leur congé de l'hôpital. Les critères d'évaluation secondaires comprenaient l'incidence de nausées et vomissements postopératoires (NVPO), la nécessité d'une analgésie postopératoire et la durée de séjour en salle de réveil (SDR). RéSULTATS: Le délai médian [écart interquartile (ÉIQ)] jusqu'à la disposition au congé de l'hôpital était significativement plus court chez les patientes ayant reçu des blocs paravertébraux pour une chirurgie de cancer du sein plutôt qu'une AG (groupe intrapandémie, 119 [99-170] min vs groupe prépandémie, 191 [164­234] min; P < 0,001), tout comme l'incidence de NVPO (3 % vs 11 %; P = 0,03) et les durées médianes [ÉIQ] de séjour en salle de réveil (29 [21­39] min vs 46 [37­63] min; P < 0,001). CONCLUSION: Les patientes qui ont reçu des blocs paravertébraux pour une chirurgie de cancer du sein dans le groupe intrapandémie étaient prêtes à quitter l'hôpital plus tôt, ont passé moins de temps en salle de réveil et ont ressenti moins de NVPO que celles qui ont reçu une AG dans le groupe prépandémie. Avec des temps d'attente pour accès à la chirurgie de plus en plus longs, des préoccupations liées aux interventions génératrices d'aérosols et les recommandations d'éviter l'AG lorsque possible, les blocs paravertébraux ont offert des avantages aux patientes et aux équipes médicales en tant que principale modalité anesthésique pour la chirurgie de cancer du sein.

Impact of chronic treatment by ß1-adrenergic antagonists on Nociceptive-Level (NOL) index variation after a standardized noxious stimulus under general anesthesia: a cohort study.

During the perioperative period, nociception control is certainly one of the anesthesiologist's main objectives when assuming care of a patient. There exists some literature demonstrating that the nociceptive stimuli experienced during surgery are responsible for peripheral and central sensitization phenomena, which can in turn lead to persistent postsurgical pain. An individualized approach to the evaluation and treatment of perioperative nociception is beneficial in order to avoid the sensitization phenomena that leads to prolonged postoperative pain and to minimize the consumption of opiates and their adverse effects. In terms of sensitivity, specificity, and positive/negative predictive values when compared to heart rate (HR) and mean arterial pressure (MAP), recent literature has shown that the NOL variation (ΔNOL) is the best index to distinguish noxious from non-noxious stimuli. Chronic treatment with ß1-adrenergic antagonists may constitute a limitation to the use of the NOL index. ß1-adrenergic antagonists induce a depressive action on the heart rate, which results in a limitation of its variability after a noxious stimulus. Since heart rate and heart rate variability are two parameters integrated into the NOL index, the validity of the NOL index in a population of patients receiving ß1-adrenergic antagonists has not yet been determined. Our study sought to explore the NOL index, the BIS, and the heart rate variation in a group of patients under chronic treatment with ß1-adrenergic antagonists submitted to standardized noxious stimulus under general anesthesia. We then compared those results to a control group of patients from our previous study (CJA group) that received no ß1-adrenergic antagonist chronic treatment. The patients in this study were subjected to a standardized anesthetic protocol from induction up to 3 min after a standardized tetanic stimulus to the ulnar nerve at a frequency of 100 Hz and an amperage of 70 mA, for a duration of 30 s. Data were electronically recorded to obtain NOL, BIS, and heart rate values every 5 s for the duration of the protocol. The NOL maximal mean value reached after noxious stimulation was not different between our two cohorts (CJA: 30(14) versus BETANOL: 36(14) (p = 0.12)). There was no statistically significant difference between our cohorts in regards of the NOL AUC representing the variation of the NOL over a 180 s period (CJA: 595(356) versus BETANOL: 634(301) (p = 0.30)). However, a repeated measurement ANCOVA identified slight statistically significant differences between our cohorts in the peak of variation of the NOL index between 20 and 65 s after noxious stimulation, the NOL index of the cohort of beta-blocked patients being higher than the CJA patients. Moreover, the time to reach the maximum value was not different (CJA: 73(37) versus BETANOL: 63(41) (p = 0.35)). NOL sensitivity and specificity to detect a noxious stimulus under general anesthesia were similar in patients taking beta-blockers or not, and were better than those of heart rate and Bispectral index (AUC NOL 0.97, CI(0.92-1), versus AUC BIS 0.78, CI(0.64-0.89) and AUC HR 0.66, CI(0.5-0.8)). In conclusion, the NOL index is a reliable monitor to assess nociception in a population of patients under chronic beta-blocker therapy. Patients under such therapy achieve similar maximal NOL values over a 180 s period after a standardized noxious stimulus and the NOL variation over time, represented by the AUC is not significantly different from a cohort of non-beta-blocked patients. Whether the patient takes beta-blockers or not, sensitivity of the NOL index is greater than that seen for BIS index or heart rate to detect an experimental noxious stimulus under general anesthesia.

Face transplantation: anesthesia and other organizational considerations.

In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.

RéSUMé: En 2005, la première allogreffe de tissu composite vascularisée faciale était réalisée en France. En mai 2018, notre équipe à l'Hôpital Maisonneuve-Rosemont, à Montréal, au Québec, a eu le privilège de participer à la première greffe faciale au Canada. La collaboration, la coordination et la communication interdisciplinaires ont constitué les pierres angulaires de ce projet médical et, ultimement, de son succès. Ce compte-rendu détaille les considérations anesthésiques et organisationnelles de notre expérience.

Assessment of fluid responsiveness with end-tidal carbon dioxide using a simplified passive leg raising maneuver: a prospective observational study.

BACKGROUND: Assessing fluid responsiveness is important in the management of patients with hemodynamic instability. Passive leg raising (PLR) is a validated dynamic method to induce a transient increase in cardiac preload and predict fluid responsiveness. Variations in end-tidal carbon dioxide (ETCO2) obtained by capnography correlate closely with variations in cardiac output when alveolar ventilation and carbon dioxide production are kept constant. In this prospective observational study, we tested the hypothesis that variations in ETCO2 induced by a simplified PLR maneuver can track changes in the cardiac index (CI) and thus predict fluid responsiveness. METHOD: A five-minute standardized PLR maneuver was performed in 90 paralyzed hemodynamically stable cardiac surgical patients receiving mechanical ventilation. Cardiac index was measured by thermodilution before and one minute after PLR. End-tidal CO2 measurements using capnography were obtained during the entire PLR maneuver. Fluid responsiveness was defined as a 15% increase in the CI. The Chi square test and Student's t test were used to compare responders and non-responders. Logistic regression analyses were then performed to determine factors of responsiveness. RESULTS: There were no differences between responders and non-responders in demographic and baseline hemodynamic variables. Fluid responsiveness was associated with an ETCO2 variation (ΔETCO2) of ≥ 2 mmHg during PLR [odds ratio (OR), 7.3; 95% confidence interval (CI), 2.7 to 20.2; P < 0.01; sensitivity 75%]. A low positive predictive value (54%) and a high negative predictive value (NPV) (86%) were observed. No other clinical or hemodynamic predictors were associated with fluid responsiveness. A logistic regression model established that a combination of ΔETCO2 ≥ 2 mmHg and a change in systolic blood pressure ≥ 10 mmHg induced by passive leg raising was predictive of fluid responsiveness (OR, 8.9; 95% CI, 2.5 to 32.2; P = 0.005). CONCLUSION: Use of a passive leg raising maneuver to induce variation in ETCO2 is a noninvasive and useful method to assess fluid responsiveness in paralyzed cardiac surgery patients receiving mechanical ventilation. Given its high NPV, fluid responsiveness is unlikely if a passive leg raising maneuver induces ΔETCO2 of < 2 mmHg.

Oncologic specimen from laparoscopic assisted gastrectomy for gastric adenocarcinoma is comparable to D1-open surgery: the experience of a Canadian centre.

BACKGROUND: The Eastern experience has reported the safety of laparoscopic assisted gastrectomy (LAG) for gastric cancer. Its use in Western countries is still debated owing to concerns about its oncologic equivalence to open gastrectomy (OG). We sought to review and compare their operative outcomes and oncologic specimen quality (number of harvested lymph nodes and surgical margins) for gastric adenocarcinoma (GA). METHODS: We reviewed the charts of all patients undergoing LAG (2007-2010) and OG (2000-2010) for GA in a single institution. Several surgeons performed the OGs, whereas 1 fellowship-trained laparoscopic surgeon performed LAGs. The primary outcome was quality of the surgical specimen, assessed by the number of harvested lymph nodes (LNs) and margin status. Secondary outcomes were perioperative events. Data were analyzed as intention to treat. RESULTS: We retrieved 60 cases (47 OGs, 13 LAGs). The conversion rate was 23%. Mean operative time was 115 minutes longer and blood loss was 425 mL less (both p < 0.001) for LAGs. A mean of 14.4 (standard deviation [SD] 9.8) and 11.2 (SD 8.2) LNs were harvested for OGs and LAGs, respectively (p = 0.29). Negative margins were achieved for all patients. Mean length of stay was similar (LAG: 19 d v. OG: 18.9 d; p = 0.91). The groups did not differ on major postoperative complications (12.7% v. 23.1%; p = 0.39) or operative mortality (2.1% v. 7.7%; p = 0.32). CONCLUSION: Laparoscopic assisted gastrectomy is a challenging but safe and feasible procedure in experienced hands. It offers the same radical resection as OG regarding negative margins and LN retrieval. Long-term follow-up is warranted.

CONTEXTE: La gastrectomie assistée par laparoscopie (GAL) a été démontrée dans des études orientales comme sécuritaire dans le traitement de l'adénocarcinome gastrique (AG). En occident, l'équivalence oncologique de la GAL avec la gastrectomie ouverte (GO) demeure cependant controversée. Cette étude vise à comparer le devenir postopératoire et la qualité des spécimens oncologiques de ces interventions, dans le traitement de l'AG. MÉTHODES: Tous les dossiers de patients opérés par GAL (2007­2010) ou GO (2000­2010) pour AG dans un seul centre hospitalier ont été revus. Différents chirurgiens ont réalisé les GO. Toutes les GAL ont été réalisées par un seul chirurgien sur-spécialisé en chirurgie laparoscopique. Le critère d'évaluation principal était la qualité du spécimen chirurgical évaluée par le nombre de ganglions lymphatiques (GL) prélevés et le statut des marges de résection. Le critère d'évaluation secondaire était la morbidité postopératoire. Les données ont été analysées en fonction de l'intention de traiter. RÉSULTANTS: Soixante cas ont été inclus (47 GO, 13 GAL). Le taux de conversion s'est établi à 23 %. Le temps opératoire moyen était plus long de 115 minutes, et les pertes sanguines moyennes moindres de 425 mL (p < 0,001 dans les 2 cas) pour la GAL que pour la GO. Une moyenne de 14,4 (écart-type [ET] 9,8) et 11,2 (ET 8,2) GL ont été prélevés respectivement pour la GO et la GAL (p = 0.29). On a obtenu des marges négatives pour tous les patients. La durée moyenne du séjour ne différait pas (GAL 19 j c. GO 18,9 j; p = 0,91). Les complications majeures (12,7 % c. 23,1 %; p = 0,39) et la mortalité post-opératoires (2,1 % c. 7,7 %; p = 0,32) étaient similaires. CONCLUSIONS: La gastrectomie assistée par laparoscopie est une intervention complexe, mais peut être réalisée de manière sécuritaire en des mains expertes. Elle offre un spécimen oncologique comparable à la gastrectomie ouverte, en termes de lymphadénectomie et de marges de résection. Un suivi à long terme demeure nécessaire.