High Frequency Jet Ventilation or Mechanical Ventilation for Panendoscopy for Cervicofacial Cancer: A Retrospective Study.

Introduction-the upper airway panendoscopy, performed under general anesthesia, is mandatory for the diagnosis of cervicofacial cancer. It is a challenging procedure because the anesthesiologist and the surgeon have to share the airway space together. There is no consensus about the ventilation strategy to adopt. Transtracheal high frequency jet ventilation (HFJV) is the traditional method in our institution. However, the COVID-19 pandemic forced us to change our practices because HFJV is a high risk for viral dissemination. Tracheal intubation and mechanical ventilation were recommended for all patients. Our retrospective study compares the two ventilation strategies for panendoscopy: high frequency jet ventilation (HFJV) and mechanical ventilation with orotracheal intubation (MVOI). Methods-we reviewed all panendoscopies performed before the pandemic in January and February 2020 (HFJV) and during the pandemic in April and May 2020 (MVOI). Minor patients, patients with a tracheotomy before or after, were excluded. We performed a multivariate analysis adjusted on unbalanced parameters between the two groups to compare the risk of desaturation. Results-we included 182 patients: 81 patients in the HFJV group and 80 in the MVOI group. After adjustments based on BMI, tumor localization, history of cervicofacial cancer surgery, and use of muscle relaxants, the patients from the HFJV group showed significantly less desaturation than the intubation group (9.9% vs. 17.5%, ORa = 0.18, p = 0.047). Conclusion-HFJV limited the incidence of desaturation during upper airway panendoscopies in comparison to oral intubation.

Intraoperative Monitoring of Neuromuscular Blockade.

There is a global trend of new guidelines highly recommending quantitative neuromuscular monitoring in the operating room. In fact, it is almost certain that quantitatively monitoring the depth of intraoperative muscle paralysis may permit the rational use of muscle relaxants and avoid some of the major related complications, namely postoperative pulmonary complications. A specific culture related to this issue is necessary to integrate quantitative monitoring of muscle relaxants as part of a major monitoring entity in anesthetized patients. For this purpose, it is necessary to fully understand the physiology, pharmacology and concept of monitoring as well as the choice of pharmacological reversal, including the introduction of sugammadex a decade ago.

Impact of Preemptive Postoperative Pressure Support Ventilation and Physiotherapy on Postoperative Pulmonary Complications after Major Cervicofacial Cancer Surgery: A before and after Study.

Introduction: Complex cervicofacial cancer surgery with free flap reconstruction is known to have a high incidence of postoperative pulmonary complications (PPCs). We hypothesized that by implementing an optimized respiratory protocol, including preemptive postoperative pressure support ventilation, physiotherapy, and critical respiratory support and follow-up, we could decrease the incidence of PPCs. Patients and methods: We evaluated the incidence of PPCs over two periods in two groups of patients having a routine or optimized postoperative respiratory protocol: 156 adult patients undergoing major cervicofacial cancer surgery were assessed; 91 were in Group 1 (routine) and 65 were in Group 2 (optimized). In Group 1, no ventilatory support sessions were performed. The incidence of pulmonary complications in both groups was compared using a multivariate analysis. Mortality was also compared until one year postoperatively. Results: In Group 2 with an optimized protocol, the mean number of ventilatory support sessions was 3.7 ± 1 (minimum 2, maximum 6). The incidence of respiratory complications, which was 34% in Group 1 (routine), was reduced by 59% OR = 0.41 (0.16; 0.95), p = 0.043) to 21% for the optimized Group 2. No difference in mortality was found. Conclusions: The present retrospective study showed that using an optimized preemptive respiratory pressure support ventilation combined with physiotherapy after a major cervicofacial surgery could possibly help reduce the incidence of pulmonary complications. Prospective studies are needed to verify these findings.

Opioid Reduced Anesthesia in Major Oncologic Cervicofacial Surgery: A Retrospective Study.

Opioid sparing is one of the new challenges in anesthesia and perioperative medicine. Opioid reduced anesthesia (ORA) is part of this approach, and it consists of a multimodal analgesia-associating non-opioid analgesic regional anesthesia to reduce intraoperative opioid requirements. Major cervicofacial oncologic surgery could specifically benefit from ORA, since it is known to generate intense and prolonged postoperative pain, with a high risk of pulmonary complications. METHODS: This is a retrospective case-controlled study of 172 patients with major cervicofacial oncologic surgery. Group ORA (dexmedetomidine and lidocaine), n = 86, was compared to patients treated with standard opioid based anesthesia, Group control, n = 86. The main endpoint was to study perioperative opioid consumption and postoperative pain scores, and the secondary endpoint was to observe opioid related side effects. RESULTS: The ORA group received 6.2 ± 3.1 mg morphine titration at the end of surgery, while the control group received 10.1 ± 3.7 mg p < 0.0001; there was no significant difference in post-operative analgesia requirements and pain scores between the groups. Intraoperatively, the ORA protocol yielded bradycardia in 4 persons, while in the control group, only 2 persons had bradycardia necessitating intervention, p < 0.05. Postoperatively, episodes of hypoxemia (50%) and the need for additional pressure-assisted ventilation (6%), was significantly different in the ORA group than in the control group (70% and 19%), p < 0.05. There was no difference between the two groups for the incidence of nausea and vomiting, ileus, or postoperative delirium. DISCUSSION: ORA was not associated with a decrease in postoperative pain and opioid requirement, but possibly reduced the incidence of hypoxemia and the use of additional pressure-assisted ventilation, although we cannot rule out confounding factors. The possible benefits of ORA remain to be demonstrated by prospective studies.

Sugammadex in Emergency Situations.

Sugammadex may be required or used in multiple emergency situations. Moderate and high doses of this compound can be used inside and outside the operating room setting. In this communication, recent developments in the use of sugammadex for the immediate reversal of rocuronium-induced neuromuscular blockade were assessed. In emergency surgery and other clinical situations necessitating rapid sequence intubation, the tendency to use rocuronium followed by sugammadex instead of succinylcholine has been increasing. In other emergency situations such as anaphylactic shock caused by rocuronium or if intubation or ventilation is not possible, priority should be given to resuming ventilation maintaining hemodynamic stability, in accordance with the traditional guidelines. If necessary for the purpose of resuming ventilation, reversal of neuromuscular blockade should be done in a timely fashion.

Impact of extending prevention of postoperative nausea and vomiting for cancer surgical patients in the PACU: a before and after retrospective study

Abstract Backgrounds Procedures for Postoperative Nausea and Vomiting (PONV) prevention are mostly based on identification of the risk factors before administering antiemetic drugs. The purpose of this study was to evaluate the impact of the extended use of antiemetic on the PONV in the Postanesthetic Care Unit (PACU). Methods Two separate 4-year periods (2007-2010, P1, and (2015-2018, P2) were evaluated. During P1, the protocol consisted of dexamethasone and droperidol for patients with a locally adapted high PONV score, followed by ondansetron for rescue in the PACU. For Period 2, dexamethasone (8 mg) and ondansetron (4 mg) were administered in patients under general or regional anesthesia, or sedation longer than 30 minutes, while droperidol (1.25 mg) in rescue was injected in cases of PONV in the PACU. An Anesthesia Information Management System was used to evaluate the intensity score of PONV (1 to 5), putative compliance, sedation, and perioperative opioid consumption upon arrival in the PACU. Results A total of 27,602 patients were assessed in P1 and 36,100 in P2. The administration of dexamethasone and ondansetron increased several fold (p < 0.0001). The high PONV scores were more improved in P2 than in P1, with scores (3+4+5) for P1 vs. P2, p < 0.0001. Overall, 99.7% of the patients in P2 were asymptomatic at discharge. Morphine consumption decreased from 6.9±1.5 mg in P1 to 3.5 ± 1.5 mg in P2 (p < 0.0001). Discussion The extension of pharmacological prevention of PONV was associated with a decrease in the intensity of severe PONV. However, uncertainty regarding confounding factors should not be ignored. IRB nº 92012/33465

Continuous Ropivacaine Peroneal Nerve Infiltration for Fibula Free Flap in Cervicofacial Cancer Surgery: A Randomized Controlled Study.

Introduction: Pain after cervicofacial cancer surgery with free flap reconstruction is both underestimated and undertreated. There is a rational for regional anesthesia at the flap harvest site, but few studies describe it. We assessed the influence of common peroneal nerve infiltration on pain and opioid consumption in patients having oropharyngeal cancer surgery with fibular free flap mandibular reconstruction. Methods: After institutional review board (IRB) approval and written informed consent, fifty-six patients were randomly allocated to perineural catheter with ropivacaine infiltration (ROPI) or systemic analgesia (CONTROL). In the ROPI group, an epidural catheter was placed by the surgeon before closure, and ropivacaine 0.2% 15 mL, followed by 4 mL/h during 48 h, was administered. The primary outcomes were pain scores and morphine consumption during the 48 h postoperative period. We also measured ropivacaine concentration at the end of infusion. Finally, we retrospectively assessed long-term pain up to 10 years using electronic medical charts. Results: Perineural infiltration of ropivacaine significantly reduced pain scores at the harvest site only at day 1, and did not influence overall postoperative opioid consumption. Ropivacaine assay showed a potentially toxic concentration in 50% of patients. Chronic pain was detected at the harvest site in only one patient (ROPI group), and was located in the cervical area in the case of disease progression. Discussion: Although the catheter was visually positioned by the surgeon, continuous ropivacaine infiltration of the common peroneal nerve did not significantly reduce postoperative pain, but induced a blood concentration close to the toxic threshold at day 2. Further studies considering other infiltration locations or other dosing schemes should be tested in this context, both to improve efficacy and reduce potential toxicity.

Adding Low-Dose Propofol to Limit Anxiety during Target-Controlled Infusion of Remifentanil for Gastrointestinal Endoscopy: Respiratory Issues and Safety Recommendations.

Backgroundand Objectives: Remifentanil-based sedation is one of many protocols proposed for endoscopy procedures in spontaneous ventilation, alone or in combination with propofol. However, the effect of these small doses of propofol on the efficacy and safety of remifentanil target-controlled infusion (TCI) deserves to be examined in this context. The objective of this study was to assess the adverse respiratory and cardiovascular effects of small boluses of propofol combined with remifentanil, in comparison with remifentanil alone, and balanced with the quality of sedation and recovery. Materials andMethods: This was an observational bicenter study, representing a subgroup of a larger study describing remifentanil-based procedural sedation. In center 1, patients scheduled for gastrointestinal (GI) endoscopy had remifentanil TCI alone. In center 2, patients had a 10 mg propofol bolus before TCI and other boluses were allowed during the procedure. Remifentanil TCI was started at a target of 2 ng/mL then adapted by 0.5 ng/mL steps according to patient response to endoscopy stimulations. Results: Center 1 included 29 patients, while center 2 included 60 patients. No difference was found in the patients' characteristics, incidence of success, average remifentanil consumption, or cardiovascular variables. Light sedation was achieved when propofol was added. The incidence of respiratory events, such as bradypnea, desaturation < 90%, and apnea requiring rescue maneuvers, were significantly higher with propofol. Conclusions: Adding propofol boluses to a remifentanil TCI for GI endoscopy ensures light sedation that may be necessary for anxiolysis but increases respiratory events, even after administration of small-dose boluses. Its safety is acceptable if the procedure is performed in an equipped environment with sedation providers trained to manage respiratory events and drugs titrated to minimal doses.

Serum Albumin Kinetics in Major Ovarian, Gastrointestinal, and Cervico Facial Cancer Surgery.

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

Clinical Update on Patient-Controlled Analgesia for Acute Postoperative Pain.

Patient-controlled analgesia (PCA) is an effective method for controlling acute pain, including postoperative pain in adults and in children from five years of age, pain resulting from labor, trauma, or other medical situations, or chronic and malignant pain. The treatment consists of a mini-computer-controlled infusion pump permitting the administration of on-demand, continuous, or combined doses of analgesic (mainly opioid) variations in response to therapy, which allows pain to be significantly controlled. Intravenous (IV)-PCA minimizes individual pharmacodynamics and pharmacokinetic differences and is widely accepted as a reference method for mild or severe postoperative pain. IV-PCA is the most studied route of PCA; other delivery methods have been extensively reported in the literature. In addition, IV-PCA usually voids the gap between pain sensation and analgesic administration, permitting better recovery and fewer side effects. The most commonly observed complications are nausea and vomiting, pruritus, respiratory depression, sedation, confusion and urinary retention. However, human factors such as pharmacy preparation and device programming can also be involved in the occurrence of these complications, while device failure is much less of an issue.

Impact of extending prevention of postoperative nausea and vomiting for cancer surgical patients in the PACU: a before and after retrospective study.

BACKGROUNDS: Procedures for Postoperative Nausea and Vomiting (PONV) prevention are mostly based on identification of the risk factors before administering antiemetic drugs. The purpose of this study was to evaluate the impact of the extended use of antiemetic on the PONV in the Postanesthetic Care Unit (PACU). METHODS: Two separate 4-year periods (2007...2010, P1, and (2015...2018, P2) were evaluated. During P1, the protocol consisted of dexamethasone and droperidol for patients with a locally adapted high PONV score, followed by ondansetron for rescue in the PACU. For Period 2, dexamethasone (8 mg) and ondansetron (4 mg) were administered in patients under general or regional anesthesia, or sedation longer than 30 minutes, while droperidol (1.25 mg) in rescue was injected in cases of PONV in the PACU. An Anesthesia Information Management System was used to evaluate the intensity score of PONV (1 to 5), putative compliance, sedation, and perioperative opioid consumption upon arrival in the PACU. RESULTS: A total of 27,602 patients were assessed in P1 and 36,100 in P2. The administration of dexamethasone and ondansetron increased several fold (p < 0.0001). The high PONV scores were more improved in P2 than in P1, with scores (3+4+5) for P1 vs. P2, p < 0.0001. Overall, 99.7% of the patients in P2 were asymptomatic at discharge. Morphine consumption decreased from 6.9..1.5 mg in P1 to 3.5 .. 1.5 mg in P2 (p < 0.0001). DISCUSSION: The extension of pharmacological prevention of PONV was associated with a decrease in the intensity of severe PONV. However, uncertainty regarding confounding factors should not be ignored. IRB: n.. 92012/33465.

End-Tidal Carbon Dioxide Pressure Measurement after Prolonged Inspiratory Time Gives a Good Estimation of the Arterial Carbon Dioxide Pressure in Mechanically Ventilated Patients.

BACKGROUND: End-tidal carbon dioxide pressure (PetCO2) is unreliable for monitoring PaCO2 in several conditions because of the unpredictable value of the PaCO2-PetCO2 gradient. We hypothesised that increasing both the end-inspiratory pause and the expiratory time would reduce this gradient in patients ventilated for COVID-19 with Acute Respiratory Distress Syndrome and in patients anaesthetised for surgery. METHODS: On the occasion of an arterial blood gas sample, an extension in inspiratory pause was carried out either by recruitment manoeuvre or by extending the end-inspiratory pause to 10 s. The end-expired PCO2 was measured (expiratory time: 4 s) after this manoeuvre (PACO2) in comparison with the PetCO2 measured by the monitor. We analysed 67 Δ(a-et)CO2, Δ(a-A)CO2 pairs for 7 patients in the COVID group and for 27 patients in the anaesthesia group. Results are expressed as mean ± standard deviation. RESULTS: Prolongation of the inspiratory pause significantly reduced PaCO2-PetCO2 gradients from 11 ± 5.7 and 5.7 ± 3.4 mm Hg (p < 0.001) to PaCO2-PACO2 gradients of -1.2 ± 3.3 (p = 0.043) and -1.9 ± 3.3 mm Hg (p < 0.003) in the COVID and anaesthesia groups, respectively. In the COVID group, PACO2 showed the lowest dispersion (-7 to +6 mm Hg) and better correlation with PaCO2 (R2 = 0.92). The PACO2 had a sensitivity of 0.81 and a specificity of 0.93 for identifying hypercapnic patients (PaCO2 > 50 mm Hg). CONCLUSIONS: Measuring end-tidal PCO2 after prolonged inspiratory time reduced the PaCO2-PetCO2 gradient to the point of obtaining values close to PaCO2. This measure identified hypercapnic patients in both intensive care and during anaesthesia.

Incidence of Severe Hypothermia and Its Impact on Postoperative Surgical Complications and Time Delay to Adjunct Treatments in Breast Surgery Cancer Patients: A Case-Controlled Study.

INTRODUCTION: Unintended postoperative hypothermia frequently occurs upon arrival in the post anesthesia care unit (PACU). As part of our quality assurance program in anesthesia, we regularly monitor the incidence of this complication through our anesthesia information management system (AIMS). In this case-controlled retrospective study, our goal was to detect the incidence of unintended severe hypothermia in our breast surgery cancer patients, and subsequently to analyze the consequence of this complication in terms postoperative cutaneous infection, as well as its impact on further complementary treatment, such as radiotherapy and chemotherapy. METHODS: This study was a retrospective analysis conducted through our AIMS system from 2015 through 2019, with extraction criteria based on year, type of surgery (breast), and temperature upon arrival in PACU. A tympanic temperature of less than 36 °C was considered to indicate hypothermia. Severe hypothermia was considered for patients having a temperature lower than 35.2 °C (hypothermic) (n = 80), who were paired using a propensity score analysis with a control group (normothermic) (n = 80) of other breast cancer surgery patients. Extracted data included time of surgery, sex, age, ASA status, and type and duration of the intervention. RESULTS: The mean incidence of hypothermia was 21% from 2015 through 2019. The body mass index (BMI) was significantly lower in the hypothermia group before matching, 23.5 ± 4.1 vs. 26.4 ± 6.1 kg/m2 in normothermic patients (p < 0.05). The hypothermia group also had significantly fewer monitoring and active warming devices. No difference was noted for wound complications. Time to complementary chemotherapy and or radiotherapy did not differ between groups (52 ± 21 days in group hypothermia vs 49 ± 22 days in the control group). CONCLUSION: Severe intraoperative hypothermia remains an important quality assurance issue in our breast surgery cancer patients, but we could not detect any long-term effect of hypothermia.

Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial.

OBJECTIVE: To assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery. DESIGN: Phase III, randomised, double blind, placebo controlled trial. SETTING: 34 centres in France, December 2017 to March 2019. PARTICIPANTS: 1222 adults (>50 years) requiring major non-cardiac surgery with an expected duration of more than 90 minutes. The anticipated time frame for recruitment was 24 months. INTERVENTIONS: Participants were randomised to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Randomisation was stratified on the two prespecified criteria of cancer and thoracic procedure. MAIN OUTCOMES MEASURES: The primary outcome was a composite of postoperative complications or all cause mortality within 14 days after surgery, assessed in the modified intention-to-treat population (at least one treatment administered). RESULTS: Of the 1222 participants who underwent randomisation, 1184 (96.9%) were included in the modified intention-to-treat population. 14 days after surgery, 101 of 595 participants (17.0%) in the dexamethasone group and 117 of 589 (19.9%) in the placebo group had complications or died (adjusted odds ratio 0.81, 95% confidence interval 0.60 to 1.08; P=0.15). In the stratum of participants who underwent non-thoracic surgery (n=1038), the primary outcome occurred in 69 of 520 participants (13.3%) in the dexamethasone group and 93 of 518 (18%) in the placebo group (adjusted odds ratio 0.70, 0.50 to 0.99). Adverse events were reported in 288 of 613 participants (47.0%) in the dexamethasone group and 296 of 609 (48.6%) in the placebo group (P=0.46). CONCLUSIONS: Dexamethasone was not found to significantly reduce the incidence of complications and death in patients 14 days after major non-cardiac surgery. The 95% confidence interval for the main result was, however, wide and suggests the possibility of important clinical effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov NCT03218553.

Comparison of Train of Four Measurements with Kinemyography NMT DATEX and Accelerography TOFscan.

INTRODUCTION: This study was designed to compare the Datex neuromuscular transmission (NMT) kinemyography (NMTK) device with the TOFscan (TS) accelerometer during the onset and recovery of neuromuscular blockade. PATIENTS AND METHODS: This prospective study included adult patients who were scheduled to undergo elective surgery with general anesthesia and orotracheal intubation. The TS accelerometer was randomly placed at the adductor pollicis on one hand, and the NMTK was placed on the opposite arm. Anesthesia was initiated with remifentanil target-controlled infusion (TCI) and 2.0-3.0 mg/kg of propofol. Thereafter, 0.5 mg/kg of atracurium or 0.6 mg/kg of rocuronium was injected. If needed, additional neuromuscular blocking agents were administered to facilitate surgery. First, we recorded the train of four (TOF) response at the onset of neuromuscular blockade to reach a TOF count of 0. Second, we recorded the TOF response at the recovery of neuromuscular blockade to obtain a T4/T1 90% by both TS and NMTK. RESULTS: There were 32 patients, aged 38-83 years, with the American Society of Anesthesiologists (ASA) Physical Status Classification I-III included and analyzed. Surgery was abdominal, gynecologic, or head and neck. The Bland and Altman analysis for obtaining zero responses during the onset showed a bias (mean) of 2.7 s (delay) of TS in comparison to NMTK, with an upper/lower limit of agreement of [104; -109 s] and a bias of 36 s of TS in comparison to NMTK, with an upper/lower limit of agreement of [-21.8, -23.1 min] during recovery (T4/T1 > 90%). CONCLUSIONS: Under the conditions of the present study, the two devices are not interchangeable. Clinical decisions for deep neuromuscular blockade should be made cautiously, as both devices appear less accurate with significant variability.

Comparison of the Time to Extubation and Length of Stay in the PACU after Sugammadex and Neostigmine Use in Two Types of Surgery: A Monocentric Retrospective Analysis.

Sugammadex provides a rapid pharmacological reversal of aminosteroid, as well as fewer pulmonary complications, a better physiological recovery, and shorter stays in the postanesthetic recovery unit (PACU). This retrospective analysis of our Centricity anesthesia database in 2017-2019 assessed the efficiency of sugammadex in real-life situations in two groups of surgical cancer patients (breast and abdominal surgery) based on the extubation time, operating room exit time, and length of PACU stay. Overall, 382 anesthesia records (131 breast and 251 abdominal surgeries) were extracted for the pharmacological reversal of neuromuscular blockades by neostigmine or sugammadex. Sugammadex was used for reversal in 91 breast and 204 abdominal surgeries. Sugammadex use did not affect the extubation time, operating room exit time, or length of PACU stay. However, the time to reach a 90% train of four (TOF) recovery was significantly faster in sugammadex patients: 2 min (1.5-8) in breast surgery and 2 min (1.5-7) in abdominal surgery versus 10 (6-20) and 9 min (5-20), respectively, for neostigmine (p < 0.05). Most patients who were reversed with sugammadex (91%) reached a TOF ratio of at least 90%, while 54% of neostigmine patients had a 90% TOF ratio recorded (p < 0.05). Factors other than pharmacological reversal probably influence the extubation time, operating room exit time, or PACU stay; however, sugammadex reliably shortened the time so as to reach a 90% TOF ratio with a better level of reversal.

Efficacy of target controlled infusion of remifentanil with spontaneous ventilation for procedural sedation and analgesia (Remi TCI PSA): A double center prospective observational study.

OBJECTIVE: Remifentanil, a rapid onset rapid offset synthetic opioid and potent analgesic, is often used for procedural conscious sedation in spontaneous ventilation, especially when delivered in target controlled infusion (TCI), which allows precise titration. We assessed efficacy, tolerance, and adverse events related with the use of remifentanil TCI during various procedures. DESIGN: Prospective, observational. SETTING: Two teaching hospitals. PATIENTS: We enrolled 434 patients undergoing procedures suitable for conscious sedation. INTERVENTIONS: The following procedures considered suitable were included: interventional radiology, gastrointestinal (GI) endoscopy, interventional cardiology, and peripheral dermatology. Sedation options were determined during the preoperative anesthesia assessment. MAIN OUTCOME MEASURES: Demographics were recorded as well as success rate, remifentanil dosage, pain scores, respiratory or cardiovascular events, and patient and operator satisfaction. RESULTS: The procedure was successful in 429 patients (99 percent), canceled in four patients because of agitation, apnea, desaturation, and converted to general anesthesia in two for major pain. The maximal remifentanil target was around 2-3 ng/ml for most procedures, but it was 3-5 ng/ml for GI endoscopy and urology. A total of 172 patients (40 percent) had bradypnea < 8 min-1, but only 26 (6 percent) had hypoxemia < 90 percent. Eighteen patients (4 percent) required mandibular luxation, and twelve needed face mask ventilation. There were no major cardiovascular adverse events. CONCLUSIONS: Remifentanil TCI is a suitable protocol for procedural sedation, but respiratory depression is a permanent concern. This risk requires equipped environment and competent medical personnel on hand to adjust the target before hypoxemia occurs. Respiratory rate monitoring, based on capnography or thoracic impedance is of a great help in anticipating this threat.

Guidelines on muscle relaxants and reversal in anaesthesia.

OBJECTIVES: To provide an update to the 1999 French guidelines on "Muscle relaxants and reversal in anaesthesia", a consensus committee of sixteen experts was convened. A formal policy of declaration and monitoring of conflicts of interest (COI) was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE®) system to assess the quality of the evidence on which the recommendations were based. The potential drawbacks of making strong recommendations based on low-quality evidence were stressed. Few of the recommendations remained ungraded. METHODS: The panel focused on eight questions: (1) In the absence of difficult mask ventilation criteria, is it necessary to check the possibility of ventilation via a facemask before muscle relaxant injection? Is it necessary to use muscle relaxants to facilitate facemask ventilation? (2) Is the use of muscle relaxants necessary to facilitate tracheal intubation? (3) Is the use of muscle relaxants necessary to facilitate the insertion of a supraglottic device and management of related complications? (4) Is it necessary to monitor neuromuscular blockade for airway management? (5) Is the use of muscle relaxants necessary to facilitate interventional procedures, and if so, which procedures? (6) Is intraoperative monitoring of neuromuscular blockade necessary? (7) What are the strategies for preventing and treating residual neuromuscular blockade? (8) What are the indications and precautions for use of both muscle relaxants and reversal agents in special populations (e.g. electroconvulsive therapy, obese patients, children, neuromuscular diseases, renal/hepatic failure, elderly patients)? All questions were formulated using the Population, Intervention, Comparison and Outcome (PICO) model for clinical questions and evidence profiles were generated. The results of the literature analysis and the recommendations were then assessed using the GRADE® system. RESULTS: The summaries prepared by the SFAR Guideline panel resulted in thirty-one recommendations on muscle relaxants and reversal agents in anaesthesia. Of these recommendations, eleven have a high level of evidence (GRADE 1±) while twenty have a low level of evidence (GRADE 2±). No recommendations could be provided using the GRADE® system for five of the questions, and for two of these questions expert opinions were given. After two rounds of discussion and an amendment, a strong agreement was reached for all the recommendations. CONCLUSION: Substantial agreement exists among experts regarding many strong recommendations for the improvement of practice concerning the use of muscle relaxants and reversal agents during anaesthesia. In particular, the French Society of Anaesthesia and Intensive Care (SFAR) recommends the use of a device to monitor neuromuscular blockade throughout anaesthesia.

End-Expiratory Occlusion Test to Predict Fluid Responsiveness Is Not Suitable for Laparotomic Surgery.

BACKGROUND: The end-expiratory occlusion test predicts fluid responsiveness in ventilated intensive care patients; however, its utility in the operating room is questioned. We assessed end-expiratory occlusion test in laparotomic surgery for predicting volume expansion. METHODS: Forty-six patients were included in this study: stage 1 (n = 26) with an end-expiratory occlusion test of 15 seconds, followed by volume expansion, which consisted of 250 mL of colloid over 5 minutes and stage 2 (n = 20) with an end-expiratory occlusion test of 25 seconds followed by volume expansion. The last 10 patients had transdiaphragmatic pressures probed. Patients with an increase in cardiac index >15% after volume expansion were responders. Pulse pressure variation, stroke volume (SV) index, and cardiac index were analyzed. Receiver operating characteristic curves were established for changes in SV and pulse pressure induced by end-expiratory occlusion test and pulse pressure variation using the responders status for volume expansion as outcome. RESULTS: A total of 44 (38%) volume expansions were deemed responders. After end-expiratory occlusion test of 15 seconds, no hemodynamic variables were significantly increased. After end-expiratory occlusion test of 25 seconds, SV index increased in responders (37.1 ± 8.8 mL/m after end-expiratory occlusion test of 25 seconds versus 35.7 ± 8.6 before; P < .0001). End-expiratory occlusion test could not discriminate responders from nonresponders. Only pulse pressure variation had significantly different area under the curve from that expected by chance (0.7 [0.57-0.81]; P = .002 for end-expiratory occlusion test of 15 seconds; and 0.78 [0.64-0.89]; P = .0001 for end-expiratory occlusion test of 25 seconds). After laparotomy, gastric pressure decreased significantly (4 [2.75-5] vs 2 [2-4] cm H2O; P = .0417); no difference was noticed in the transdiaphragmatic gradient. CONCLUSIONS: End-expiratory occlusion test was not reliable to discriminate responders from nonresponders after volume expansion during laparotomic surgery.