Objectives Inadequate postoperative pain control is common and is associated with poor clinical outcomes. This study aimed to identify preoperative predictors of poor postoperative pain control in adults undergoing inpatient surgery. Design Systematic review and meta-analysis Data sources MEDLINE, Embase, CINAHL and PsycINFO were searched through October 2017. Eligibility criteria Studies in any language were included if they evaluated postoperative pain using a validated instrument in adults (≥18 years) and reported a measure of association between poor postoperative pain control (defined by study authors) and at least one preoperative predictor during the hospital stay. Data extraction and synthesis Two reviewers screened articles, extracted data and assessed study quality. Measures of association for each preoperative predictor were pooled using random effects models. Results Thirty-three studies representing 53 362 patients were included in this review. Significant preoperative predictors of poor postoperative pain control included younger age (OR 1.18 [95% CI 1.05 to 1.32], number of studies, n=14), female sex (OR 1.29 [95% CI 1.17 to 1.43], n=20), smoking (OR 1.33 [95% CI 1.09 to 1.61], n=9), history of depressive symptoms (OR 1.71 [95% CI 1.32 to 2.22], n=8), history of anxiety symptoms (OR 1.22 [95% CI 1.09 to 1.36], n=10), sleep difficulties (OR 2.32 [95% CI 1.46 to 3.69], n=2), higher body mass index (OR 1.02 [95% CI 1.01 to 1.03], n=2), presence of preoperative pain (OR 1.21 [95% CI 1.10 to 1.32], n=13) and use of preoperative analgesia (OR 1.54 [95% CI 1.18 to 2.03], n=6). Pain catastrophising, American Society of Anesthesiologists status, chronic pain, marital status, socioeconomic status, education, surgical history, preoperative pressure pain tolerance and orthopaedic surgery (vs abdominal surgery) were not associated with increased odds of poor pain control. Study quality was generally high, although appropriate blinding of predictor during outcome ascertainment was often limited. Conclusions Nine predictors of poor postoperative pain control were identified. These should be recognised as potentially important factors when developing discipline-specific clinical care pathways to improve pain outcomes and to guide future surgical pain research. PROSPERO registration number CRD42017080682.

https://bmjopen.bmj.com/content/bmjopen/9/4/e025091.full.pdf

Preoperative predictors of poor acute postoperative pain control: a systematic review and meta-analysis

We evaluated the procedure of postoperative inhalational sedation with sevoflurane using the Anaesthetic Conserving Device (ACD) with regard to recovery times, feasibility and consumption of anaesthetics in comparison to propofol. Prospective, randomised, single-blinded, controlled study in a surgical intensive care unit (ICU) of a 1,000-bed academic hospital. A total of 70 patients after elective coronary artery bypass graft surgery either received sevoflurane via ACD (n = 35) or propofol (n = 35) for short-term postoperative sedation in the ICU. The primary endpoint was extubation time from termination of sedation. Recovery times, consumption of anaesthetics, endtidal sevoflurane concentrations, length of ICU and hospital stay, and side effects were documented. Mean recovery times were significantly shorter with sevoflurane than with propofol (extubation time: 22 vs. 151 min; following commands: 7 vs. 42 min). The mean (SD) sevoflurane consumption was 3.2 ± 1.4 mL/h to obtain mean endtidal concentrations of 0.76 vol%. No serious complications occurred during sedation with either sedative drug. The length of ICU stay was comparable in both groups, but hospital length of stay was significantly shorter in the sevoflurane group. Drug costs (in Euro) for sedation per patient were similar in both groups (sevoflurane: 15.1 ± 9.5 €; propofol: 12.5 ± 5.8 €), while sevoflurane sedation costs that included use of the ACD were significantly higher. Sevoflurane administration via ACD is an effective and safe alternative to propofol to provide postoperative short-term ICU sedation. Recovery from sedation was facilitated with sevoflurane instead of propofol and resulted in shorter extubation and ventilator times. Neurology/sedation, Sedation and anaesthesia.

https://link.springer.com/content/pdf/10.1007%2Fs00134-008-1157-x.pdf

Short-term sevoflurane sedation using the Anaesthetic Conserving Device after cardiothoracic surgery.

https://www.criticalcare.theclinics.com/article/S0749-0704(09)00038-4/pdf

Pharmacology of sedative-analgesic agents: dexmedetomidine, remifentanil, ketamine, volatile anesthetics, and the role of peripheral mu antagonists.

The purpose of the Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea (OSA) is to present recommendations based on current scientific evidence. This guideline seeks to address questions regarding the intraoperative care of patients with OSA, including airway management, anesthetic drug and agent effects, and choice of anesthesia type. Given the paucity of high-quality studies with regard to study design and execution in this perioperative field, recommendations were to a large part developed by subject-matter experts through consensus processes, taking into account the current scientific knowledge base and quality of evidence. This guideline may not be suitable for all clinical settings and patients and is not intended to define standards of care or absolute requirements for patient care; thus, assessment of appropriateness should be made on an individualized basis. Adherence to this guideline cannot guarantee successful outcomes, but recommendations should rather aid health care professionals and institutions to formulate plans and develop protocols for the improvement of the perioperative care of patients with OSA, considering patient-related factors, interventions, and resource availability. Given the groundwork of a comprehensive systematic literature review, these recommendations reflect the current state of knowledge and its interpretation by a group of experts at the time of publication. While periodic reevaluations of literature are needed, novel scientific evidence between updates should be taken into account. Deviations in practice from the guideline may be justifiable and should not be interpreted as a basis for claims of negligence.

Society of Anesthesia and Sleep Medicine Guideline on Intraoperative Management of Adult Patients With Obstructive Sleep Apnea.

As most critically ill or injured patients will require some degree of sedation, the goal of this paper was to comprehensively review the literature associated with use of sedative agents in the intensive care unit (ICU). The first and selected latter portions of this article present a narrative overview of the shifting paradigm in ICU sedation practices, indications for uninterrupted or prolonged ICU sedation, and the pharmacology of sedative agents. In the second portion, we conducted a structured, although not entirely systematic, review of the available evidence associated with use of alternative sedative agents in critically ill or injured adults. Data sources for this review were derived by searching OVID MEDLINE and PubMed from their first available date until May 2012 for relevant randomized controlled trials (RCTs), systematic reviews and/or meta-analyses and economic evaluations. Advances in the technology of mechanical ventilation have permitted clinicians to limit the use of sedation among the critically ill through daily sedative interruptions or other means. These practices have been reported to result in improved mortality, a decreased length of ICU and hospital stay and a lower risk of drug-associated delirium. However, in some cases, prolonged or uninterrupted sedation may still be indicated, such as when patients develop intracranial hypertension following traumatic brain injury. The pharmacokinetics of sedative agents have clinical importance and may be altered by critical illness or injury, co-morbid conditions and/or drug-drug interactions. Although use of validated sedation scales to monitor depth of sedation is likely to reduce adverse events, they have no utility for patients receiving neuromuscular receptor blocking agents. Depth of sedation monitoring devices such as the Bispectral Index (BIS©) also have limitations. Among existing RCTs, no sedative agent has been reported to improve the risk of mortality among the critically ill or injured. Moreover, although propofol may be associated with a shorter time to tracheal extubation and recovery from sedation than midazolam, the risk of hypertriglyceridaemia and hypotension is higher with propofol. Despite dexmedetomidine being linked with a lower risk of drug-associated delirium than alternative sedative agents, this drug increases risk of bradycardia and hypotension. Among adults with severe traumatic brain injury, there are insufficient data to suggest that any single sedative agent decreases the risk of subsequent poor neurological outcomes or mortality. The lack of examination of confounders, including the type of healthcare system in which the investigation was conducted, is a major limitation of existing pharmacoeconomic analyses, which likely limits generalizability of their results.

/pdf/sedation-for-critically-ill-or-injured-adults-in-the-4vgxzykw0r.pdf

Sedation for critically ill or injured adults in the intensive care unit: a shifting paradigm

BACKGROUND: The AnaConDa filter permits administration of volatile anesthetic without the use of an anesthesia machine. It is intended for use in the intensive care unit. METHODS: We studied the AnaConDa reflection filter on the bench and in anesthetized patients. The bench analysis used a test lung, a gas analyzer, an intensive care ventilator, the AnaConDa filter, and a syringe pump. We studied a range of tidal volume, respiratory rate, and positive end-expiratory pressure values. We simulated errors during syringe refilling and patient transportation. In 15 anesthetized patients, we used the AnaConDa with constant ventilation variables, a constant sevoflurane infusion rate (4–5 mL/h), and two consecutive fresh gas flow levels. RESULTS: In the bench study, the expired volatile anesthetic fraction decreased linearly with respiratory frequency at constant minute ventilation, and decreased markedly in a hyperbolical manner when tidal volume increased at a constant respiratory rate. Changing the positive end-expiratory pressure level and inspiration/expiration ratio did not modify the AnaConDa’s performance. Several safety failures were observed: refilling caused a transient change in AnaConDa output because of a pumping effect, and a standard Luer lock made it possible to connect the halogenate syringe on an IV infusion line. In anesthetized patients, reducing fresh gas flow from 8 to 1 L/min led to a median 40% increase in the expired volatile anesthetic fraction. CONCLUSIONS: This study shows that the device is generally reliable, but that there are several conditions under which it might deliver more anesthetic than intended. (Anesth Analg 2007;104:130‐4)

Anaconda® Reflection Filter: Bench and Patient Evaluation of Safety and Volatile Anesthetic Conservation

Background and aims Patients with obstructive sleep apnoea (OSA) have a high risk of postoperative complications. The purpose of the study was to record the spectrum and frequency of postoperative complications in patients with OSA versus (vs.) without OSA depending on the type of surgery and type of anaesthesia in a large cohort of patients. Methods We conducted a prospective, descriptive study (n = 400). Ethics Committee approval was obtained and written informed consent was signed. The Berlin screening questionnaire was used for OSA screening (77.2% - OSA [+]). Adverse events and complications were recorded postoperatively (AOS [+] vs. AOS [-]). Statistics: Chi square test. Results The highest rate of complications was found in patients who had underwent surgery in the abdominal cavity under general anaesthesia, AOS [+] vs. AOS [-]: cardiovascular [56.4%] vs. [7.5%], respiratory [17.6%] vs. [3.5%], stroke [0.7%] vs. [0.0% ], prolonged awakening from anaesthesia [2.5%] vs. [0.0%], postoperative fever [1.4%] vs. [0.3%], difficult orotracheal intubation [3.5%] vs. [0.3% ], unscheduled transfer to the intensive care unit [5.7%] vs. [0.0%]. Conclusions OSA [+] patients who underwent abdominal surgery under general anaesthesia had a higher rate of complications compared to OSA [-] patients, and also compared to patients who had undergone peripheral limb surgery. Surgery on the musculoskeletal system is much better tolerated by patients with OSA, suffering a lower number and range of events and postoperative complications. Loco-regional anaesthesia should be considered a priority in patients with OSA.

/pdf/the-prevalence-of-perioperative-complications-in-patients-x02e0l0fdm.pdf

The prevalence of perioperative complications in patients with and without obstructive sleep apnoea: a prospective cohort study.

BACKGROUND AND AIMS Effective postoperative analgesia is a key element in reducing postoperative morbidity, accelerating recovery and avoiding chronic postoperative pain. The aim of this study was to evaluate the effectiveness of ultrasound-guided Transversus Abdominis Plane (TAP) block, performed before surgical incision, in providing postoperative analgesia for patients undergoing open ventral hernia repair under general anaesthesia. METHODS Seventy elective patients scheduled for open ventral hernia repair surgery under general anaesthesia were divided randomly into two equal groups: Group I received bilateral TAP block performed before surgical incision (n = 35); Group II received systemic postoperative analgesia with parenteral opioid (morphine) alone (n = 35). Postoperatively pain scores at rest and with movement, total morphine consumption and opioid related side effects were recorded. RESULTS Postoperative pain scores at rest and mobilization/cough were significantly higher in patients without TAP block (p < 0.05). Mean intraoperative fentanyl consumption was comparable between the two groups: 0.75 ± 0.31 mg in group I (TAP) and 0.86 ± 0.29 mg in group II (MO), p = 0.1299. Patients undergoing preincisional TAP block had reduced morphine requirements during the first 24 hours after surgery, compared to patients from group II, without TAP block (p = 0.0001). There was no difference in the incidence of opioid related side effects (nausea, vomiting) in the both groups during the first 24 postoperative hours. CONCLUSION The use of preincisional ultrasound guided TAP block reduced the pain scores at rest and with movement/cough, opioid consumption and opioid-related side effects after ventral hernia repair when compared with opioid-only analgesia.

/pdf/postoperative-analgesic-efficiency-of-transversus-abdominis-14tgqbtwax.pdf

Postoperative analgesic efficiency of transversus abdominis plane block after ventral hernia repair: a prospective, randomized, controlled clinical trial.

Resume Type d'etude. – Le but de cette etude etait d'evaluer les caracteristiques de la formation medicale continue (FMC) des anesthesistes–reanimateurs francais (AR). Methodes. – Un questionnaire de 73 items a ete adresse par courrier a un echantillon de 1000 AR dont la repartition par region, par sexe et par type d'etablissement refletait la repartition nationale. Un second envoi a ete realise six semaines apres en cas de non-reponse. Resultats. – Le taux de reponses a ete de 40,8 %. Les repondants sont similaires a la population des AR francais, en termes d'activite, d'âge, de type d'exercice professionnel. L'adhesion aux societes savantes francaises d'anesthesie reanimation s'eleve a 72 % auxquels s'ajoutent 24 % d'affiliations a des societes d'autres disciplines. La frequentation de congres francophones s'eleve a 81 % qui sont apprecies de facon similaire ; mais seulement 17 % des AR assistent a des congres internationaux. Les congres generalistes sont preferes par 67 % des AR. Annuellement, on recense une mediane de six jours en congres plus quatre jours de stage ; 89 % des AR lisent des revues medicales (37 % etrangeres). La formation est partiellement prise en charge financierement dans 61 % des cas. Internet est utilise en FMC par 73 % des AR sur des sites francophones. Les facteurs temps et financier sont les deux principales limites invoquees pour la FMC. Conclusion. – La FMC est un phenomene etabli en France au vu de nos resultats. L'ouverture vers les interfaces internationales reste cependant modeste.

Enquête nationale sur la formation médicale continue des anesthésistes–réanimateurs

We present a reflection on pharmaco-economy of perioperative pain management A real optimisation of expenses could be obtained if taking into consideration factors that augment and diminish costs of the process, due to the organisation of the process itself, due to optimisation of the information and decision's circuits The cost of an analgesic is not significant when compared with the cost of entire process of pain management

Les aspects pharmacoéconomiques dans la gestion de la douleur périopératoire

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