Ketamine for pain management in France, an observational survey

International audienceContext: Before updating the French guidelines on postoperative pain treatment in 2015, the Pain Committee of the French Society of Anaesthesiology and Intensive Care (SFAR) conducted a survey on the medical use of ketamine in France. Methods: An online questionnaire was nationally distributed to members of SFAR, the French Pain Society (SFETD) and the French Society of Emergency Medicine (SFMU). The questionnaire included questions on demographic data, the type of patients for whom ketamine was prescribed, the doses used, the side effects and safety measures associated with the administration of ketamine. Results: A total of 1388 questionnaires were analysed. Ninety-two percent of the responders declared that they used ketamine. Ketamine was widely used as anti-hyperalgesic medication but the modalities of administration and the doses varied greatly and were not in accordance with the guidelines. Despite the lack of evidence and guidelines, ketamine has also been used to treat acute and chronic pain. Doses, duration and localization of the patients during administration have varied greatly. Psychedelic effects and hallucinations are the most feared side effects. In terms of monitoring during ketamine infusion, 15% of physicians declared that no monitoring was necessary while 59%, 55%, 59% and 77% monitored heart rate, SpO2, blood pressure and level of consciousness, respectively. Conclusion: Anaesthesiologists have integrated the benefit of ketamine in preventing hyperalgesia but there is no consensus on doses and duration. For other indications (acute and chronic pain treatment), toxicity and the absence of significant benefit call for guidelines from scientific societie

Les AINS en périopératoire : élargir les indications, respecter les contre-indications

National audienceno abstrac

Opioid-free anesthesia

International audienceOpioid Free Anesthesia (OFA) is emerging as a new stimulating research perspective. The rationale to propose OFA is based on the aim to avoid the negative impact of intraoperative opioid on patient's postoperative outcomes and also on the physiology of pathways involved in intraoperative nociception. It is based on the concept of multimodal anesthesia. OFA has been shown to be feasible but the literature is still scarce on the clinically meaningful benefits for patients as well as on the side effects and / or complications that might be associated with it. This review focused first on the physiology of nociception, the reasons for using or not opioids during anesthesia, and then on the literature reporting evidence-based proofs of benefits / risks associated with OFA. Practice points: • OFA is a multimodal anesthesia associating drugs and/or techniques that allows a good quality general anesthesia with no need for opioids 2 • Anti-nociception during general anesthesia can be obtained by interfering with various neuromediators not only by interfering with enkephalins with opioids • Studies have shown that OFA allows a postoperative morphine sparing, PONV reduction and a trend towards a reduction of opioid-related adverse event

Anesthésie sans opiacés

National audienceLes opiacés de synthèse sont utilisés depuis les années 1960 pour limiter les effets des agents hypnotiques, faciliter la stabilité hémodynamique et la ventilation mécanique. Ils ont montré leurs limites : effets secondaires doses dépendants, hyperalgésie, source paradoxale de douleur aiguë et chronique etc… Sur le modèle du concept d’épargne morphinique en analgésie postopératoire, l’anesthésie sans opiacés (« opioid-free anaesthesia » ou OFA en anglais) est une technique alternative En peropératoire, les objectifs d’hypnose, de stabilité hémodynamique, d’immobilisation et d’anticipation de l’analgésie postopératoire sont réalisables sans morphiniques. C’est une anesthésie multimodale associant différentes techniques et/ou médicaments. La dexmedetomidine est un alpha-2-agoniste qui a montré son intérêt en peropératoire d’une OFA. Les premières études sur les bénéfices de l’OFA montrent une épargne morphinique importante associée à une réduction des scores de douleur en postopératoire et une réduction des nausées et vomissements. Le niveau de preuve dans la littérature reste faible, il manque encore beaucoup d’études pour réellement évaluer le bénéfice et la place de l’OFA

Comment utiliser les antalgiques non opiacés en postopératoire ? [Postoperative non-opioid analgesics management.]

National audienc

Opioid-Sparing Techniques in Orthopedic Anesthesia-One Step to Opioid-Free Anesthesia?

International audienceOpioid-free anesthesia is a multimodal anesthesia aimed at avoiding the negative impact of intraoperative opioid on patient’s postoperative outcomes. It is based on the physiology of pathways involved in intraoperative nociception. It has been shown to be feasible but the literature is still scarce on the clinically meaningful benefits as well as on the side effects and/or complications that might be associated with it. Moreover, most studies involved abdominal and/or bariatric surgery. Procedure-specific studies are lacking, especially in orthopedics

Initiatives to broaden safety concerns in anaesthetic practice: The green operating room

International audienceThe health sector is a major contributor to climate change through its large carbon footprint. Hospitals are highly energy and resource intensive. Operating rooms (ORs) contribute to a major part of these emissions because of anaesthetic gases, energy-intensive equipment and waste. Besides initiatives aimed to mitigate hospitals’ climate footprints, health care professionals need to be involved in this process by changing their professional and personal behaviours without compromising the quality of care. Education on metrics (greenhouse gases), concepts (life cycle) and strategies to reduce the health care footprint would help professionals to commit themselves to the issue. The 5R’s rule (reduce, reuse, recycle, rethink and research) used to promote an environmentally friendly way of life can be applied to the medical field and especially to the operating room and anaesthesia. When applied in the ORs, these strategies help question the use of disposable devices, attires and packaging, as well as our professional and personal behaviour. Greening the ORs requires the engagement of all professionals as well as other departments (pharmacy, hygiene) and management. Economic and social co-benefits are expected from this process

Enhanced recovery after hepatectomy : a systematic review

International audienceBackground: Hepatectomy is a surgery with high postoperative complication rates. Enhanced recovery after surgery (ERAS) clinical pathways in liver surgery have been studied and may become a standard of care. However, few specific recommendations have been published so far.Objective: The aim of this study was to assess the efficacy and safety of the enhanced recovery program in liver surgery.Methods: Randomised controlled trials (RCTs) comparing ERAS group with traditional care published between 2007 and 2017 were included in this review. The outcomes were length of stay (LoS), complications, mortality and readmission rate for all liver surgeries except transplantation.Results: Five hundred and twenty-four patients randomised in 4 RCTs were analysed. Two hundred and fifty-four patients were in ERAS group and 270 patients in traditional care (TC) group. Two studies compared cares in laparoscopic surgery and 2 in open surgery. Postoperative LoS was significantly lower in the ERAS group whereas readmission and mortality rate were similar. ERAS group had also significant lower complication rate in 2 studies of the 4. The complication rate in the 2 other studies was similar.Conclusion: ERAS protocols in liver surgery appeared to be safe and effective. Recent recommendations from the ERAS group in liver surgery are the only ones published so far. Other studies evaluating ERAS components in liver surgery and recommendations from scientific societies are needed to spread this clinical care pathway

Douleur périopératoire et conséquences à court et moyen terme [Perioperative pain and its consequences]

National audienceRecent advances in the management of perioperative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain preoperatively, preoperative opioid use, and the intensity of postoperative pain. Ideal management of perioperative pain in 2016 aims to optimize postoperative pain management, to detect the risk of pain chronicity begins preoperatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in postoperative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer (Sacerdote et al., 2012), and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intraoperative and postoperative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications.Les avancées récentes dans la prise en charge de la douleur périopératoire concernent principalement la reconnaissance du risque de chronicisation. L’existence d’une douleur préopératoire, la prise de morphiniques en préopératoire et l’intensité de la douleur postopératoire sont les facteurs de risque les mieux identifiés. La gestion de la douleur périopératoire en 2016 doit permettre d’optimiser la prise en charge postopératoire, de détecter, en préopératoire, les risques de chronicisation de la douleur et de détecter les facteurs précoces de chronicisation. En termes de traitement, l’utilisation systématique et large de la morphine a montré ses limites, notamment avec une efficacité moindre sur les douleurs au mouvement, des effets secondaires pouvant être très invalidants pour le patient et retarder la réhabilitation postopératoire, un effet hyperalgésique dose-dépendante source de douleur aiguë et chronique, une immunomodulation pouvant avoir un impact négatif sur des pathologies infectieuses ou cancéreuses (Sacerdote et al., 2012) et enfin, un doute sur une possible neurotoxicité. C’est pourquoi, l’analgésie moderne est basée sur la recherche d’une épargne morphinique en per- et postopératoire. L’objectif en 2016 est donc une analgésie optimale permettant une réhabilitation rapide sans séquelles ou chronicisation utilisant des médicaments et/ou techniques permettant de s’affranchir des morphiniques. Recent advances in the management of perioperative pain principally concern the recognition of the risk of developing pain chronicity. The best identified risk factors for pain chronicity are the presence of pain preoperatively, preoperative opioid use, and the intensity of postoperative pain. Ideal management of perioperative pain in 2016 aims to optimize postoperative pain management, to detect the risk of pain chronicity begins preoperatively with early detection of risk factors for chronicity. In terms of treatment, the systematic and generous use of morphine has shown its limitations, particularly due to reduced efficacy for movement-related pain. Meanwhile, opioid side effects can be very debilitating for the patient, leading to delay in postoperative rehabilitation, a dose-dependent hyperalgesic effect resulting in both acute and chronic pain, immune modulation that may have a deleterious impact on infectious complications or cancer (Sacerdote et al., 2012), and, finally, some question of possible neurotoxicity. Therefore, modern analgesia depends on both intraoperative and postoperative morphine sparing. The goal at the present time is to obtain optimal analgesia that allows rapid rehabilitation without sequelae or chronicity through the use of drugs and/or techniques to avoid the need for opioid medications

Sustainability of anaesthesia components of an enhanced recovery program (ERP) in colorectal and orthopaedics surgery

International audienceBackground - Sustainability of ERP is a challenge and data are scarce on the subject. The aim of this study was to assess if application of enhanced recovery elements through the Francophone Group of Enhanced Recovery after Surgery (Grace) in the anaesthesia management was sustainable 2 years after its implementation. Materials and methods - We conducted a retrospective analysis of the prospective Grace database between October 2014 and October 2016. The evolution of each recommendation item over time was analysed using non-parametric Spearman correlation coefficient. Results - A total of 67 and 43 centres corresponding to 2067 and 3022 patients participated to the Grace audit in colorectal and orthopaedics surgery, respectively. Colorectal surgery: Mean length of stay was 5 (±4) days and readmission rate was 6.6%. Application of most items did not statistically change. It worsened over time for PONV prophylaxis (P=0.01) and prevention of intraoperative hypothermia (P=0.02); and improved for NSAID administration (P=0.01). Orthopaedics surgery: Mean length of stay was 3 (±2) days and readmission rate was 1.7%. There was a trend towards improvement for most items. It reached statistical significance for PONV prophylaxis (P=0.001), limited preoperative fasting (P=0.01). While the use of a perineural catheter (P=0.001) decreased over time, infiltration of the surgical site statistically increased (P=0.05). Conclusion - This study shows on a large scale a trend towards less application of all ERP items over time. Continuous audits should be encouraged to expect further improvements