Opioid-free versus opioid-based anesthesia in pancreatic surgery.

BACKGROUND: Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear. METHODS: Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes. RESULTS: Compared to OBA, NRS (3 [2-4] vs 0 [0-2], P < 0.001) and opioid consumption (36 [24-52] vs 10 [2-24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7-46] vs 10 [6-16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups. CONCLUSIONS: In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

The Acquisition of Multidrug-Resistant Bacteria in Patients Admitted to COVID-19 Intensive Care Units: A Monocentric Retrospective Case Control Study.

Whether the risk of multidrug-resistant bacteria (MDRB) acquisition in the intensive care unit (ICU) is modified by the COVID-19 crisis is unknown. In this single center case control study, we measured the rate of MDRB acquisition in patients admitted in COVID-19 ICU and compared it with patients admitted in the same ICU for subarachnoid hemorrhage (controls) matched 1:1 on length of ICU stay and mechanical ventilation. All patients were systematically and repeatedly screened for MDRB carriage. We compared the rate of MDRB acquisition in COVID-19 patients and in control using a competing risk analysis. Of note, although we tried to match COVID-19 patients with septic shock patients, we were unable due to the longer stay of COVID-19 patients. Among 72 patients admitted to the COVID-19 ICUs, 33% acquired 31 MDRB during ICU stay. The incidence density of MDRB acquisition was 30/1000 patient days. Antimicrobial therapy and exposure time were associated with higher rate of MDRB acquisition. Among the 72 SAH patients, 21% acquired MDRB, with an incidence density was 18/1000 patient days. The septic patients had more comorbidities and a greater number of previous hospitalizations than the COVID-19 patients. The incidence density of MDRB acquisition was 30/1000 patient days. The association between COVID-19 and MDRB acquisition (compared to control) risk did not reach statistical significance in the multivariable competing risk analysis (sHR 1.71 (CI 95% 0.93-3.21)). Thus, we conclude that, despite strong physical isolation, acquisition rate of MDRB in ICU patients was at least similar during the COVID-19 first wave compared to previous period.

Brain Aging and Anesthesia.

Herein, the authors review the neuroanatomical and the neurophysiological aspects of the normal aging evolution based on the recent literature and briefly describe the difference between physiological and pathological brain aging, with consideration of the currently recommended anesthesia management of older patients. The population of elderly patients is growing drastically with advances in medicine that have prolonged the life span. One of the direct consequence has been a significant increase in the request for anesthesia care for older patients despite the type of surgery (cardiac vs noncardiac and mainly orthopedic). Because the brain of this category of patients undergoes a specific triple influence (immune, metabolic, and inflammatory), some particular physiological, anatomical, and structural modifications must be taken into account because they expose these patients more specifically to postoperative cognitive disturbances. To prevent type of adverse outcome, a better knowledge and understanding of these neurosciences must be promoted. The strategies developed to prevent such adverse outcomes include the determination and detection of significant at-risk patients and improvement in the titration of anesthesia to reduce exposure of anesthesia to these patients through an adapted anesthesia-induced unconsciousness that avoids, as much as possible, the risk of toxic overdose with an overly deep brain depression. To accomplish this, the unprocessed electroencephalogram (EEG) and its spectrogram may represent a significant improvement in monitoring, first by allowing for the rapid recognition of repetitive or persistent EEG suppression by the on-line reading of the raw EEG trace and second by allowing for the accurate determination of the adequate anesthetic-induced state, obtained in general in this category of patients by substantially lowered doses of anesthetic agents. This represents a new methodology for anesthesia titration that is adjusted on a more case-by-case basis and is related to the physiology of individual patients. A better understanding of aging-induced brain transformations remains the key regarding the improvement of the anesthetic management of the always growing population of elderly patients. The promotion of the unprocessed EEG may represent the best method of preventing the risk of anesthetic toxicity, including postoperative cognitive dysfunctions.