Patient experience with anesthesia

Ces 20 dernières années, la mortalité attribuable à l’anesthésie a été divisée par 10. Cette baisse de mortalité offre la possibilité de porter une attention plus importante à certains critères d’évaluation, reportés par les patients, tels que le vécu ou la satisfaction. Appliqué au contexte periopératoire, le vécu du patient peut constituer un indicateur de résultats de l’anesthésie, à classer aux côtés de la morbidité et de la mortalité. Une prémédication anxiolytique est largement pratiquée avant une intervention chirurgicale à travers le monde. Une autre stratégie répandue pour améliorer le vécu du patient consiste à réaliser une sédation prolongée au décours des interventions réalisées sous anesthésie locorégionale. Ces pratiques ne reposent que sur un faible niveau de preuve et leur efficacité n’est pas évaluée.Ce travail de thèse à permis de développer deux outils d’analyse de la période periopératoire, soit un questionnaire d’évaluation de l’anxiété préopératoire et une échelle d’évaluation du vécu periopératoire en anesthésie locorégionale. Ces outils ont été déployés au sein d’une démarche de recherche clinique afin d’évaluer formellement l’efficacité de la prémédication sédative et celle de la sédation peropératoire dans deux études prospectives randomisées distinctes. Les résultats mettent en évidence que si l’anxiété préopératoire est liée à un moins bon vécu global de la période periopératoire, la réalisation systématique d’une prémédication ou d’une sédation ne résulte pas en une meilleure expérience pour le patient et est à l’origine d’effets adverses significatifs.The last 20 years, mortality due to anesthesia was divided by 10. This decline in mortality allows to bring more attention to certain evaluation criteria, reported by patients, such as experience or satisfaction. Applied to the perioperative context, the patient experience can be a major outcome of anesthesia, alongside morbidity and mortality. Different empirical approaches, are implemented for several years to improve the patient experience. Sedative premedication is widely practiced before surgery worldwide. Another common strategy to improve the patient experience is to perform continuous sedation in interventions performed under regional anesthesia. These practices rely on a low level of evidence and their effectiveness is not evaluated. Such an assessment would require the use of validated tools together with a clinical experimental approach placing the patient experience as the primary endpoint.This thesis allowed to develop two tools for analyzing the perioperative period, i.e. an evaluation of preoperative anxiety and the assessment of perioperative patient experience in regional anesthesia. These tools have been deployed in a clinical research process to formally evaluate the effectiveness of sedative premedication and intraoperative sedation in two separate randomized studies. The results show that if preoperative anxiety is related to poorer overall experience of the perioperative period, the systematic implementation of premedication or sedation does not result in a better experience for the patient and could lead to significant adverse effects

La sédation contrôlée par le patient au propofol dans le vécu de l'artériographie

AIX-MARSEILLE2-BU Méd/Odontol. (130552103) / SudocSudocFranceF

Validation of the French version of the Amsterdam preoperative anxiety and information scale (APAIS)

International audienc

Comparison of continuous with single-injection regional analgesia on patient experience after ambulatory orthopaedic surgery: a randomised multicentre trial

Background: The optimal approach to improving patient experience and analgesia after ambulatory orthopaedic surgery remains unclear.Methods: This multicentre, randomised clinical trial compared single-injection nerve block analgesia with home delivery of continuous nerve block analgesia by remote-controlled electronic pump. The primary outcome was patient-reported satisfaction (Evaluation du Vecu de l'Anesthesie Generale [EVAN-G]; 0-100) assessed on postoperative Day 2. Secondary outcomes focused on pain, opioid consumption, quality of rehabilitation, activity tracking using a wearable electronic device, and 90-day quality of life.Results: We randomly assigned 294 patients to continuous pump delivery or single injection. For subjects with normal level of pain catastrophising (Pain Catastrophizing Scale <30; n=211), median global EVAN-G was higher with the electronic pump compared with the single injection (78 [69-86] vs 72 [63-84]; P=0.03), as were pain satisfaction scores (P=0.01). For the maximum pain levels, the numerical rating scale score was 2.0 (1.0-5.0) in the electronic-pump group vs 5.0 (3.0-7.0) in the single-injection group on the first 2 days after surgery (P<0.0001). Total opioid consumption in morphine equivalent was higher with single injection (mean [standard deviation]): 70.5 [73.8] vs 31.9 [54.2] mg; P<0.01). The groups did not differ in early rehabilitation on Day 1 or quality of life on Day 45. Electronic activity tracking indicated higher activity in the electronic-pump group (P<0.01).Conclusions: Self-reported patient satisfaction at home was better with continuous nerve block analgesia via electronic pump vs single injection, without impairing early rehabilitation. Single-injection analgesia was associated with higher pain levels and opioid consumption and lower satisfaction. Patient catastrophising negatively affected the experience of pain.Clinical trial registration: NCT02720965

Effect of Sedative Premedication on Patient Experience After General Anesthesia

International audienceIMPORTANCE:Sedative premedication is widely administered before surgery, but little clinical evidence supports its use.OBJECTIVE:To assess the efficacy of sedative premedication on perioperative patient experience.DESIGN, SETTING, AND PARTICIPANTS:A randomized clinical trial, the PremedX study, enrolled 1062 adult patients who were younger than 70 years and had been scheduled for various elective surgeries under general anesthesia at 5 French teaching hospitals (in Marseille, Montpellier, Nimes, and Nice) between January 2013 and June 2014. Neurosurgery, obstetrical, cardiac, and outpatient surgery were excluded.INTERVENTIONS:Patients were randomized to 3 groups of 354 participants each to receive 2.5 mg of lorazepam, no premedication, or placebo.MAIN OUTCOMES AND MEASURES:The primary outcome was perioperative patient experience assessed 24 hours after surgery with a validated questionnaire (Evaluation du Vécu de l'Anesthésie Generale; EVAN-G) describing 6 domains of satisfaction and a global index (score range, 0-100; high scores represent high satisfaction); secondary outcomes included time to extubation and early cognitive recovery. A subgroup analysis was planned a priori in patients with a high level of preoperative anxiety.RESULTS:Premedication with lorazepam did not improve the EVAN-G mean global index for overall level of patient satisfaction (72 [95% CI, 70-73]; n = 330) compared with no premedication (73 [95% CI, 71-74]; n = 319) or placebo (71 [95% CI, 70-73]; n = 322) (P = .38). Among patients with heightened preoperative anxiety, there were no significant differences found in the EVAN-G mean global index between the lorazepam group (68 [95% CI, 65-72]; n = 87) and the no premedication group (73 [95% CI, 69-77]; n = 57) or the placebo group (70 [95% CI, 67-72]; n = 87) (P = .18). Time to extubation was 17 minutes (95% CI, 14-20 minutes) in the lorazepam group, 12 minutes (95% CI, 11-13 minutes) for the no premedication group, and 13 minutes (95% CI, 12-14 minutes) for the placebo group (P < .001) and the rate of early cognitive recovery was 51% (95% CI, 45%-56%), 71% (95% CI, 66%-76%), and 64% (95% CI, 59%-69%), respectively (P < .001).CONCLUSIONS AND RELEVANCE:Among patients undergoing elective surgery under general anesthesia, sedative premedication with lorazepam compared with placebo or no premedication did not improve the self-reported patient experience the day after surgery, but was associated with modestly prolonged time to extubation and a lower rate of early cognitive recovery. The findings suggest a lack of benefit with routine use of lorazepam as sedative premedication in patients undergoing general anesthesia.TRIAL REGISTRATION:clinicaltrials.gov Identifier: NCT01901003

Médecine périopératoire : l’anesthésiste-réanimateur, un acteur majeur du pronostic

National audienc

Guidelines on perioperative optimization protocol for the adult patient 2023

International audienceObjective: The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs. Design: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. Methods: Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a “formalized expert recommendations” format. Results: The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations. Conclusions: Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields