Influence of compliance to antithrombotic agents on perioperative morbidity and mortality.

For patients on antithrombotic medication, the outcome of a planned surgery depends on the adjustment of their daily treatment. This study aimed to assess the impact of non-compliance to published recommendations about antithrombotic agents, specifically those provided by the Groupement d'Intérêt pour l'hémostase Peri-opératoire (GIHP), on patient morbidity and mortality.A prospective cohort observational monocentric study was conducted over a 7-month period in 2019 in an academic hospital. The study included patients on antithrombotic agents scheduled for elective surgery, excluding cardiac surgery. The primary endpoints were morbidity and mortality at 1 month according to GIHP guidelines compliance. Blood loss during surgery and length of hospital stay were secondary endpoints.Among the 589 patients included in the study, 87 complications were recorded, resulting in a morbidity rate of 14.8%. Thirty-six patients experienced hemorrhagic events, leading to 8 deaths, while 33 patients suffered from ischemic events, resulting in 3 deaths. Additionally, 18 patients died from causes unrelated to hemorrhage or ischemia. Compliance with GIHP guidelines was observed in 62% of patients. Statistical analysis did not reveal a significant association between adherence to guidelines and morbidity (p value = 0.923), nor between adherence and 1-month survival (p value = 0.698). Similarly, no statistically significant relationships were found between compliance and intraoperative bleeding volume (p value = 0.087), postoperative bleeding (p value = 0.460), or length of hospital stay (p value = 0.339).This study did not identify any substantial associations between non-strict adherence to GIHP recommendations and patient outcomes, including morbidity, mortality, and bleeding. However, it is important to interpret these findings with caution, considering the study's limitations and the need for further research in this area.

Comparison of the effectiveness of ultrasound-guided versus fluoroscopy-guided medial lumbar bundle branch block on pain related to lumbar facet joints: a multicenter randomized controlled non-inferiority study.

BACKGROUND: The aim of this multicenter randomized interventional prospective study was to compare the ultrasound (US)-guided lumbar medial branch block (LMBB) with the fluoroscopy (FS)-guided LMBB in terms of analgesic efficacy and disability in the setting of the treatment of pain arising from the lumbar facet joints (LFJ). METHODS: Fifty adults with a "LFJ" syndrome were randomized into two groups: in group FS, fluoroscopic-guidance was used to block the medial branch at three lumbar levels (L3-L4, L4-L5 and L5-S1); in group US, same blocks were performed under ultrasound. Needle transverse approach was used with both techniques. Effects of these procedures were assessed with a Visual Analogue Pain Scale (VAPS), the Oswestry Disability Index (ODI) and the Duke's Activity Status Index (DASI) scale, before the treatment, 1 week and 1 month after. Hospital Anxiety and Depression Scale (HADS) score was also collected before the procedure. Analysis of variance, one (for non-inferiority) and two-sided Mann-Whitney tests and Chi-square tests were performed. RESULTS: LMBB under US-guidance was not inferior to FS-guidance (P = 0.047) in terms of VAPS, ODI and DASI at 1 week and 1 month. Duration of techniques and HADS were similar between groups (=0.34; p = 0.59). CONCLUSIONS: The medial lumbar bundle branch block under ultrasound-guidance is not inferior to the fluoroscopy-guidance procedure in effectively alleviating pain arising from the facet joints. Considering that this ultrasound technique has the benefit of an irradiation-free, real-time procedure, it can be considered as an effective alternative to the fluoroscopy-guided technique.

Jet Ventilation Reduces Coronary Sinus Movement in Patients Undergoing Atrial Fibrillation Ablation: An Observational Crossover Study.

BACKGROUND: One of the reasons that high-frequency jet ventilation (HFJV) is used is due to the near immobility of thoracic structures. However, no study has quantified the movements of cardiac structures during HFJV compared with normal mechanical ventilation. METHODS: After ethical approval and written informed consent, we included 21 patients scheduled for atrial fibrillation ablation in this prospective crossover study. Each patient was ventilated with both normal mechanical ventilation and HFJV. During each ventilation mode, displacements of the cardiac structure were measured by the EnSite Precision mapping system using a catheter placed in the coronary sinus. RESULTS: The median [Q1-Q4] displacement was 2.0 [0.6-2.8] mm during HFJV and 10.5 [9.3-13.0] mm during conventional ventilation (p < 0.000001). CONCLUSION: This study quantifies the minimal movement of cardiac structures during HFJV compared to standard mechanical ventilation.

Lung separation in adult thoracic anesthesia.

Thoracic anesthesia is mainly the world of OLV during anesthesia. The indications for OLV, classified as absolute or relative are more representative of the new concepts in OLV: It includes either the separation or the isolation of the lungs. Modern DLTs are most widely employed worldwide to perform OLV including the concept of one lung separation. Endobronchial blockers are a valid alternative to DLTs, and they are mandatory in the education of lung separation and in case of predicted difficult airways as they are the safest approach (with an awake intubation with an SLT through a FOB). Every general anesthesiologist should know how to insert a left-sided DLT, but he/she should also have in his technical luggage and toolbox, basic knowledge and minimal expertise with BBs, this option being considered a suitable alternative, particularly in emergency situation where the patient is already intubated and/or in case of difficult airways. One should keep in mind that extubation or re-intubation after DLT might be difficult too, and additional intubation tools are necessary for the safety conditions.

Anesthesia for robotic thoracic surgery.

The management of the robotic thoracic surgical patient requires the knowledge of minimally invasive surgery techniques involving the chest. Over the past decade, robotic-assisted thoracic surgery has grown, and, in the future, it will take an important place in the treatment of complex thoracic pathologies. The enhanced dexterity and three-dimensional visualization make it possible to do this in the small space of the thoracic cavity. Familiarity with the robotic surgical system by the anesthesiologists is mandatory. Management of a long period of one-lung ventilation with a left-sided double-lumen endotracheal tube or an independent bronchial blocker is required, along with flexible fiberoptic bronchoscopy techniques (best continuous monitoring). Correct patient positioning and prevention of complications such as eye or nerve or crashing injuries while the robotic system is used is mandatory. Recognition of the hemodynamic effects of carbon dioxide during insufflation in the chest is required. Cost is higher and outcome is not yet demonstrated to be better as compared to video-assisted thoracic surgery. The possibility for conversion to open thoracotomy should also be kept in mind. Teamwork is mandatory, as well as good communication between all the actors of the operating theatre.

Earlier and lower dose administration of sugammadex: A randomised placebo-controlled trial.

BACKGROUND: Sugammadex allows for rapid reversal of muscle relaxation after the use of rocuronium or vecuronium. The lowest recommended dose is 2 mg kg-1 intravenously when there are two twitches during the train-of-four stimulation. OBJECTIVE: To study the efficacy and risks of a lower dose of sugammadex administered earlier. DESIGN: Monocentric randomised controlled double-blind study. SETTING: Academic hospital. PATIENTS: Eighty patients were enrolled and randomised in 8 groups of 10 patients, 56 were finally evaluated. INTERVENTIONS: Patients were distributed in two clusters constituting four groups each. In the first cluster, injections were administered after the return of one twitch with the train-of-four (TOF1). In the second cluster, injections were delivered after the return of two twitches with the TOF (TOF2). We created four groups in each cluster for different dosages: placebo, 0.5, 1 or 2 mg kg-1. MAIN OUTCOME MEASURES: Time between the injection of sugammadex and full recovery (TOF ratio > 0.9) that is expressed in minutes. RESULTS: Fifty-six successive patients were assessed between February and August 2018. The difference to TOF greater than 0.9 was not statistically significant between groups with the same dose administered at different times (F value = 0.001, P value = 0.975). There was a significant difference between groups with a different dosage administered at the same time (F ratio = 28.34; P value <0.0001). Concerning the time to TOF greater than 0.9 from the time point of TOF1, the timing of the dosages were statistically significant using log rank test (P < 0.0001). No patient presented a reparalysis. CONCLUSION: No difference between injecting sugammadex at TOF1 or TOF2 was found regarding time to full recovery. Difference regarding sugammadex quantity was found and compatible with other studies. TRIAL REGISTRATION: clinicaltrials.gov: 'BRIDION_ERASME', EudraCT: 2017-005074-19.

The long-term effect of complex regional pain syndrome type 1 on disability and quality of life after foot injury.

PURPOSE: To study the long-term evolution of patients with lower-limb Complex Regional Pain Syndrome (CRPS), focusing on functional and proprioceptive aspects and quality of life. METHODS: In 20 patients suffering from chronic distal lower-limb CRPS diagnosed using Budapest criteria, we assessed joint position sense and strength of the knee muscles at the CRPS and unaffected leg, functional exercise capacity, pain, CRPS severity score, quality of life and kinesiophobia. Similar assessments were performed in 20 age-matched controls. RESULTS: The joint position performance (at 45°) was significantly lower for the CRPS leg as compared to controls. The knee extensor strength of the CRPS leg was significantly reduced as compared to the unaffected leg (-27%) and controls (-42%). CRPS patients showed significantly reduced performance at the 6 min-walk test as compared to their age group predicted value and controls. Patients suffering from CRPS for 3.8 years in average still exhibit high pain, severity and kinesiophobia scores. CONCLUSIONS: Long-term deficits in strength and proprioceptive impairments are observed at the knee joint of the CRPS leg. This persistent functional disability has significant repercussions on the quality of life. We highlight the importance of including strength and proprioceptive exercises in the therapeutic approaches for CPRS patients.IMPLICATIONS FOR REHABILITATIONThe long-term evolution of patients suffering from lower-limb Complex Regional Pain Syndrome is associated with persistent disability, pain and impacts the quality of life.Strength, proprioceptive, functional and subjective assessments are necessary to better identify deficits.Rehabilitation should focus on the overall deficit of the affected and contralateral limb.

Synchronized mandibular movement and capnography: a novel approach to obstructive airway detection during procedural sedation-a post hoc analysis of a prospective study.

Perioperative complications related to obstructive sleep apnea still occur despite the use of partial pressure end-tidal CO2[Formula: see text] and pulse oximetry. Airway obstruction can complicate propofol sedation and a novel monitor combining mandibular movement analysis with capnography may facilitate its detection. Patients scheduled for sleep endoscopy were recruited and monitored with standard monitoring, [Formula: see text] and Jaw Activity (JAWAC) mandibular movement sensors. A post hoc analysis investigated airway obstruction prediction using a Respiratory Effort Sequential Detection Algorithm (RESDA) based on [Formula: see text] and mandibular movement signals. 21 patients were recruited and 54 episodes of airway obstruction occurred. RESDA detected obstructive apnea [mean ± SD (median)] 29 ± 29 (21) s, p < 0.0001, before [Formula: see text] alone. This prolonged the time between obstructive apnea detection and decrease to 90% oxygen saturation 64 ± 38 (54) versus 38 ± 20 (35) s, p < 0.0001. It predicted airway obstruction with a sensitivity and specificity of 81% and 93%, respectively. The RESDA algorithm, which is based on the combination of capnography with mandibular movement assessment of respiratory effort, can more rapidly alarm anesthetists of airway obstruction during propofol sedation than [Formula: see text] alone. However, [Formula: see text] pulse oximetry, and clinical monitoring are still required.Trial Registry numbers: ClinicalTrial.gov (NCT02909309) https://clinicaltrials.gov/ct2/show/NCT02909309 .

Comparison of the Pain Sensitivity Questionnaire and the Pain Catastrophizing Scale in Predicting Postoperative Pain and Pain Chronicization After Spine Surgery.

STUDY DESIGN: This was a prospective study evaluating the Pain Sensitivity Questionnaire (PSQ) in 110 patients undergoing spine surgery. OBJECTIVE: The purpose of this study was to compare the ability of the PSQ-total and PSQ-minor scores with the Pain Catastrophizing Scale (PCS) in predicting the immediate postoperative pain of patients after spinal surgery and their risk of developing a chronically painful state. SUMMARY OF BACKGROUND DATA: Studies evaluating the PSQ as a preoperative determinant for the development of chronic pain are lacking. Therefore, we undertook the following study. MATERIALS AND METHODS: Patients undergoing lumbar or cervical spine surgery were prospectively included in the study. The PSQ-total and PSQ-minor, the PCS and its subscores, the Oswestry Disability Index (ODI) and the Neck Disability Index were used preoperatively. Preoperative and postoperative Visual Analog Scale scores for pain at rest and movement and analgesics were recorded. At 12 months postoperatively, the Neck Disability Index and the ODI were once more assessed to evaluate pain chronicization. RESULTS: A total of 110 patients scheduled to undergo surgery at our spine center participated in the study. Our results highlighted that Visual Analog Scale scores were increased for high catastrophizers at rest on the first postoperative day when compared with low catastrophizers. Preoperative use of opioids and a high score on the rumination subscale of the PCS were linked to greater postoperative morphine consumption. At 12 months, the PCS, the PSQ-total, and PSQ-minor showed correlations with the development of a chronically painful state for ODI scores >21, indicating a marked persistent disability. CONCLUSIONS: Both PSQ and PCS showed an ability to predict a chronically painful state as defined by the persistence of disability after lumbar surgery.

3D augmented reality mirror visual feedback therapy applied to the treatment of persistent, unilateral upper extremity neuropathic pain: a preliminary study.

Objective: We assessed whether or not pain relief could be achieved with a new system that combines 3D augmented reality system (3DARS) and the principles of mirror visual feedback. Methods: Twenty-two patients between 18 and 75 years of age who suffered of chronic neuropathic pain. Each patient performed five 3DARS sessions treatment of 20 mins spread over a period of one week. The following pain parameters were assessed: (1) visual analogic scale after each treatment session (2) McGill pain scale and DN4 questionnaire were completed before the first session and 24 h after the last session. Results: The mean improvement of VAS per session was 29% (p < 0.001). There was an immediate session effect demonstrating a systematic improvement in pain between the beginning and the end of each session. We noted that this pain reduction was partially preserved until the next session. If we compare the pain level at baseline and 24 h after the last session, there was a significant decrease (p < 0.001) of pain of 37%. There was a significant decrease (p < 0.001) on the McGill Pain Questionnaire and DN4 questionnaire (p < 0.01). Conclusion: Our results indicate that 3DARS induced a significant pain decrease for patients who presented chronic neuropathic pain in a unilateral upper extremity. While further research is necessary before definitive conclusions can be drawn, clinicians could implement the approach as a preparatory adjunct for providing temporary pain relief aimed at enhancing chronic pain patients' tolerance of manual therapy and exercise intervention. Level of Evidence: 4.