Pierre Diemunsch

Consensus Guidelines for the Management of Postoperative Nausea and Vomiting

The present guidelines are the most recent data on postoperative nausea and vomiting (PONV) and an update on the 2 previous sets of guidelines published in 2003 and 2007. These guidelines were compiled by a multidisciplinary international panel of individuals with interest and expertise in PONV under the auspices of the Society for Ambulatory Anesthesia. The panel members critically and systematically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergoing surgery and are at increased risk for PONV. These guidelines identify patients at risk for PONV in adults and children; recommend approaches for reducing baseline risks for PONV; identify the most effective antiemetic single therapy and combination therapy regimens for PONV prophylaxis, including nonpharmacologic approaches; recommend strategies for treatment of PONV when it occurs; provide an algorithm for the management of individuals at increased risk for PONV as well as steps to ensure PONV prevention and treatment are implemented in the clinical setting.

Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology.

The purpose of these guidelines on the preoperative evaluation of the adult non-cardiac surgery patient is to present recommendations based on available relevant clinical evidence. The ultimate aims of preoperative evaluation are two-fold. First, we aim to identify those patients for whom the perioperative period may constitute an increased risk of morbidity and mortality, aside from the risks associated with the underlying disease. Second, this should help us to design perioperative strategies that aim to reduce additional perioperative risks. Very few well performed randomised studies on the topic are available and many recommendations rely heavily on expert opinion and are adapted specifically to the healthcare systems in individual countries. This report aims to provide an overview of current knowledge on the subject with an assessment of the quality of the evidence in order to allow anaesthetists all over Europe to integrate – wherever possible – this knowledge into daily patient care. The Guidelines Committee of the European Society of Anaesthesiology (ESA) formed a task force with members of subcommittees of scientific subcommittees and individual members of the ESA. Electronic databases were searched from the year 2000 until July 2010 without language restrictions. These searches produced 15 425 abstracts. Relevant systematic reviews with meta-analyses, randomised controlled trials, cohort studies, case–control studies and cross-sectional surveys were selected. The Scottish Intercollegiate Guidelines Network grading system was used to assess the level of evidence and to grade recommendations. The final draft guideline was posted on the ESA website for 4 weeks and the link was sent to all ESA members, individual or national (thus including most European national anaesthesia societies). Comments were collated and the guidelines amended as appropriate. When the final draft was complete, the Guidelines Committee and ESA Board ratified the guidelines.

Enhanced-reality video fluorescence: a real-time assessment of intestinal viability.

Objective:Our aim was to evaluate a fluorescence-based enhanced-reality system to assess intestinal viability in a laparoscopic mesenteric ischemia model. Materials and Methods:A small bowel loop was exposed, and 3 to 4 mesenteric vessels were clipped in 6 pigs. Indocyanine green (ICG) was administered intravenously 15 minutes later. The bowel was illuminated with an incoherent light source laparoscope (D-light-P, KarlStorz). The ICG fluorescence signal was analyzed with Ad Hoc imaging software (VR-RENDER), which provides a digital perfusion cartography that was superimposed to the intraoperative laparoscopic image [augmented reality (AR) synthesis]. Five regions of interest (ROIs) were marked under AR guidance (1, 2a-2b, 3a-3b corresponding to the ischemic, marginal, and vascularized zones, respectively). One hour later, capillary blood samples were obtained by puncturing the bowel serosa at the identified ROIs and lactates were measured using the EDGE analyzer. A surgical biopsy of each intestinal ROI was sent for mitochondrial respiratory rate assessment and for metabolites quantification. Results:Mean capillary lactate levels were 3.98 (SD = 1.91) versus 1.05 (SD = 0.46) versus 0.74 (SD = 0.34) mmol/L at ROI 1 versus 2a-2b (P = 0.0001) versus 3a-3b (P = 0.0001), respectively. Mean maximal mitochondrial respiratory rate was 104.4 (±21.58) pmolO2/second/mg at the ROI 1 versus 191.1 ± 14.48 (2b, P = 0.03) versus 180.4 ± 16.71 (3a, P = 0.02) versus 199.2 ± 25.21 (3b, P = 0.02). Alanine, choline, ethanolamine, glucose, lactate, myoinositol, phosphocholine, sylloinositol, and valine showed statistically significant different concentrations between ischemic and nonischemic segments. Conclusions:Fluorescence-based AR may effectively detect the boundary between the ischemic and the vascularized zones in this experimental model.

Ultrasonographic control of the puncture level for lumbar neuraxial block in obstetric anaesthesia

BACKGROUND Errors in the judgement of puncture level during neuraxial anaesthesia can lead to significant complications. The aim of this study was to assess, in obstetric anaesthesia, the accuracy of clinical determination of the lumbar spinal interspace level, using surface ultrasound imaging as control. METHODS At the anaesthesia follow-up visit, women who had received lumbar neuraxial anaesthesia during labour were prospectively included. The intervertebral level of needle insertion, located by the needle scar position, was identified by ultrasonography and compared with the clinical level reported on the chart by the anaesthetist who performed the block. RESULTS Ninety-nine women were studied. The clinical puncture level was accurate in 36.4% of patients. Ultrasound examination showed the puncture level to be more cephalad than the level noted in the anaesthetic record in almost 50% of patients. In 15% of patients, the puncture level was more caudad than the anaesthetist had assessed. Factors including type of anaesthesia, indication, time period, level of anaesthetic experience, BMI, and spinal pathology did not seem to influence the frequency of errors. CONCLUSIONS The observed differences between clinical and ultrasonic identification of spinal puncture level highlight the potential for serious complications associated with the performance of neuraxial blocks above the spinous process of L3 in the parturient. With the increase in popularity of techniques involving puncture of the dura mater for labour anaesthesia, we feel that awareness of this risk is important.

Skeletal muscle mitochondrial dysfunction during chronic obstructive pulmonary disease: central actor and therapeutic target

•  What is the topic of this review? Muscle dysfunction is a common complication and an important independent prognostic factor in chronic obstructive pulmonary disease (COPD). •  What advances does it highlight? In COPD patients, the vastus lateralis muscle presents with alterations that include a decrease in mitochondrial density and biogenesis, impaired mitochondrial respiration and coupling, as well as increased mitochondrial production of reactive oxygen species, possibly associated with increased mitochondrial apoptosis. These mitochondrial changes are accessible to conventional therapies, such as exercise and tobacco cessation, but potentially also to innovative management strategies, such as antioxidant treatment and supplementation with polyunsaturated fatty acids. Mitochondrial pathophysiology represents an emerging area of research in muscle dysfunction associated with COPD and has promising therapeutic implications.

Preventing postoperative nausea and vomiting: post hoc analysis of pooled data from two randomized active-controlled trials of aprepitant

ABSTRACT Objective: Compared with the 5HT3 antagonist ondansetron, the NK1 antagonist aprepitant has been shown in two double-blind trials to provide greater protection against postoperative vomiting and comparable or greater control of nausea. Post hoc analyses of pooled data from these trials were performed to more fully characterize the efficacy profile of aprepitant in terms of nausea and use of rescue therapy. Research design and methods: Patients (n = 1599) scheduled for major surgery under general anesthesia (primarily gynecological surgery) were assigned to receive a preoperative dose of aprepitant 40 mg PO, 125 mg PO, or ondansetron 4 mg IV. in two randomized, double-blind, clinical trials. Main outcome measures: Post-surgery vomiting episodes, use of rescue therapy, and nausea severity (verbal rating scale). Results: In the 24 hours after surgery, aprepitant 40 mg was more effective than ondansetron for all five endpoints evaluated: (1) no significant nausea (56.4% vs. 48.1%); (2) no nausea (39.6% vs. 33.1%); (3) no vomiting (86.7% vs. 72.4%); (4) no nausea and no vomiting (38.3% vs. 31.4%); and (5) no nausea, no vomiting, and no use of rescue (37.9% vs. 31.2%) ( p < 0.035 for the odds ratio for each comparison). Numerically more patients receiving aprepitant 125 mg also achieved these endpoints compared with ondansetron. Conclusions: These post hoc analyses confirm the favorable efficacy profile of aprepitant for the prevention of postoperative nausea and vomiting.

Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model

BACKGROUND The most effective treatment of achalasia is Heller myotomy. OBJECTIVE To explore a submucosal endoscopic myotomy technique tailored on esophageal physiology testing and to compare it with the open technique. DESIGN Prospective acute and survival comparative study in pigs (n = 12; 35 kg). SETTING University animal research center. INTERVENTION Eight acute-4 open and 4 endoscopic-myotomies followed by 4 survival endoscopic procedures. MAIN OUTCOME MEASUREMENTS Preoperative and postoperative manometry; esophagogastric junction (EGJ) distensibility before and after selective division of muscular fibers at the EGJ and after the myotomy was prolonged to a standard length by using the EndoFLIP Functional Lumen Imaging Probe (Crospon, Galway, Ireland). RESULTS All procedures were successful, with no intraoperative and postoperative complications. In the survival group, the animals recovered promptly from surgery. Postoperative manometry demonstrated a 50% drop in mean lower esophageal sphincter pressure (LESp) in the endoscopic group (mean preoperative LESp, 22.2 ± 3.3 mm Hg; mean postoperative LESp, 11.34 ± 2.7 mm Hg; P < .005) and a 69% loss in the open procedure group (mean preoperative LESp, 24.2 ± 3.2 mm Hg; mean postoperative LESp, 7.4 ± 4 mm Hg; P < .005). The EndoFLIP monitoring did not show any distensibility difference between the 2 techniques, with the main improvement occurring when the clasp circular fibers were taken. LIMITATIONS Healthy animal model; small sample. CONCLUSION Endoscopic submucosal esophageal myotomy is feasible and safe. The lack of a significant difference in EGJ distensibility between the open and endoscopic procedure is very appealing. Were it to be perfected in a human population, this endoscopic approach could suggest a new strategy in the treatment of selected achalasia patients.

Intraperitoneal nebulization of ropivacaine for pain control after laparoscopic cholecystectomy: a double-blind, randomized, placebo-controlled trial

BACKGROUND Intraperitoneal local anaesthetic nebulization is a relatively novel approach to pain management after laparoscopic surgery. This randomized, double-blind, placebo-controlled trial evaluated the effects of intraperitoneal ropivacaine nebulization on pain control after laparoscopic cholecystectomy. METHODS Patients undergoing laparoscopic cholecystectomy were randomized to receive intraperitoneal nebulization of ropivacaine 1% (3 ml) before surgical dissection and normal saline 3 ml at the end of surgery (preoperative nebulization group); intraperitoneal nebulization of normal saline 3 ml before surgical dissection and ropivacaine 1% (3 ml) at the end of surgery (postoperative nebulization group); or intraperitoneal nebulization of normal saline 3 ml before surgical dissection and at the end of surgery (placebo group). Intraperitoneal nebulization of ropivacaine or saline was performed using the Aeroneb Pro(®) device. Anaesthetic and surgical techniques were standardized. The degree of pain on deep breath or movement, incidence of shoulder pain, morphine consumption, and postoperative nausea and vomiting were collected in the post-anaesthesia care unit and at 6, 24, and 48 h after surgery. RESULTS Compared with placebo, ropivacaine nebulization significantly reduced postoperative pain (-33%; Cohens d 0.64), referred shoulder pain (absolute reduction -98%), morphine requirements (-41% to -56% Cohens d 1.16), and time to unassisted walking (up to -44% Cohens d 0.9) (P<0.01). There were no differences in pain scores between ropivacaine nebulization groups. CONCLUSIONS Ropivacaine nebulization before or after surgery reduced postoperative pain and referred shoulder pain after laparoscopic cholecystectomy. Furthermore, ropivacaine nebulization reduced morphine requirements and allowed earlier mobility.

Hématome sous durai bilatéral après analgesie péridurale

PurposeThe authors report a case of bilateral subdural hematoma (SDH) which occurred following epidural analgesia for labour, complicated by post durai puncture headache (PDPH). Physiopathological mechanisms are discussed.Clinical featuresA 27-yr-old woman displayed typical PDPH following epidural anaesthesia. On the fifth day she was given a blood patch (BP) which proved immediately effective. Further developments were marked by late recurrence of PDPH and by administration of a second BP on the 24th day. With the aggravation of the headaches, the disapearance of their postural nature and with the appearance of transitory focal neurological signs on the 30th day, a CT-Scan was done and showed bilateral subdural haematoma. Following surgical drainage, the patient made an uneventful recovery.ConclusionThe presence of PDPH complicated by a typical neurological deterioration should prompt the anaesthetist to seek an immediate clinical and x-ray diagnosis in order to look for the existence of intracranial complications.AbstractObjectifLes auteurs rapportent le cas d’un hématome sous durai (HSD) bilatéral survenu au décours d’une analgésie péridurale pour l’accouchement, compliquée de céphalées post effraction de la dure-mère. Plusieurs mécanismes physiopathologiques sont envisagés.Eléments cliniquesUne femme de 27 ans présentait des céphalées typiques dans les suites d’une analgésie péridurale obstétricale. Le 5e jour après l’accouchement, elle bénéficiait d’un pansement de sang épidural (blood patch, BP) immédiatement efficace. Lévolution était marquée par la récidive tardive de céphalées et par la réalisation d’un second BP au 24e jour. Devant l’aggravation des céphalées, la disparition de leur caractère postural et l’apparition de signes neurologiques focaux transitoires le 30e jour, on découvrait par tomodensitométrie, l’existence d’un hématome sous durai bilatéral. Lévolution fût favorable sans séquelle après son évacuation chirurgicale.Conclusion:La présence de céphalées post effraction dureméro-arachnoïdienne compliquées de signes neurologiques même discrets et transitoires doit conduire l’anesthésiste à demander un diagnostic neurologique clinique et radiologique immédiat afin de rechercher et de traiter une éventuelle complication intracrânienne.

Pooled analysis of three large clinical trials to determine the optimal dose of Dolasetron Mesylate needed to prevent postoperative nausea and vomiting

STUDY OBJECTIVE To identify the maximally effective dolasetron dose (i.e., maximum efficacy with minimum adverse events) for prevention of postoperative nausea and vomiting (PONV) using the statistical power generated in a pooled patient sample from three large, nearly identical clinical trials. DESIGN Three randomized, multicenter, placebo-controlled, double-blinded trials. SETTING Trials 1, 2, and 3 enrolled patients at 10, 25, and 17 hospitals and/or surgical centers, respectively. PATIENTS A total of 1,946 ASA physical status, I, II, and III patients. Trials 1 and 2 enrolled only female patients (n = 916) undergoing gynecologic surgery. Trial three enrolled 722 females (approximately 70% gynecologic surgeries) and 308 males (approximately 46% orthopedic surgeries) undergoing a variety of surgical procedures. INTERVENTIONS All surgical procedures used balanced general anesthesia. Patients received 12.5, 25, 50, or 100 mg of the antiemetic, dolasetron, near the end of anesthesia. MEASUREMENTS AND MAIN RESULTS Efficacy endpoints were identical and measured for 24 hours: complete response (no vomiting or rescue medication) and maximum nausea, reported using a 100-mm visual analog scale (VAS). Safety was assessed using adverse event reports, laboratory and electrocardiographic data, and vital signs. All four dolasetron doses produced significant increases in complete response and decreases in maximum VAS nausea compared with placebo (p < 0.01). No increased efficacy was observed with dolasetron doses higher than 12.5 mg. Safety was similar between each dolasetron dose and placebo. CONCLUSION Dolasetron 12.5 mg, given near the end of anesthesia, is the maximally effective dose studied for preventing postoperative nausea and vomiting.