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Purpose: Carbetocin, an oxytocin analog, given as a postpartum hemorrhage prophylaxis in elective Cesarean deliveries, frequently causes tachycardia and hypotension. Phenylephrine infusion has been shown to prevent spinal anesthesia-induced hypotension. The goal of this study was to evaluate if a slow infusion of carbetocin would reduce maternal heart rate variation and hemodynamic disturbances compared with a rapid bolus in parturients receiving a prophylactic phenylephrine infusion during elective Cesarean delivery. Methods: In this double-blinded randomized controlled trial, 70 healthy parturients were allocated to either a bolus group or an infusion group. At cord clamping, participants in the bolus group received carbetocin 100 µg as a rapid intravenous bolus, while participants in the infusion group received carbetocin 100 µg over 10 min. The primary outcome was the variation in maternal heart rate from baseline during the 20 min following cord clamping. Secondary outcomes included blood pressure, cardiac output, and stroke volume variations during the study period, measured with the ClearSight™ hemodynamic monitor. Results: Maximum heart rate variation was not different between the groups: bolus group, mean (standard deviation) 29.8 (25.2)% vsinfusion group, 27.2 (23.3)%; P= 0.67. The increase in heart rate occurred significantly earlier in the bolus group than in the infusion group (median [interquartile range] time, 105 [69–570] sec vs485 [255–762] sec; P =0.02; group × time interaction: two-way repeated measures ANOVA, P= 0.04). There was no significant difference in maximum variations for the other hemodynamic parameters between the groups. Conclusion: Carbetocin infused over ten minutes did not reduce the magnitude of maternal heart rate variation but delayed its occurrence. This finding could be relevant to the anesthesiologist caring for parturients in whom a slight increase in maternal heart rate is clinically undesirable. Study registration: www.clinicaltrials.gov(NCT03404544); registered 19 January 2018.

Background: The COVID-19 pandemic has markedly increased delays in oncologic surgeries because of the virus’s impact on traditional anesthetic management. Novel protocols, developed to protect patients and medical professionals, have altered the ways and instances in which general anesthesia (GA) can be safely performed. To reduce virus exposure related to aerosol-generating procedures, it is now recommended to avoid GA when feasible and promote regional anesthesia instead. At our institution, we observed faster postoperative recovery in patients who received paravertebral blocks for breast cancer surgery instead of GA. This led us to formally evaluate whether regional anesthesia instead of GA helped improve time to hospital discharge. Methods: We conducted a historical cohort study to retrospectively analyze two cohorts of patients: prepandemic vsintrapandemic. We obtained approval from our institutional ethics committee to review files of consecutive patients who underwent breast cancer surgery between 30 March 2020 and 30 June 2020 (intrapandemic group; N= 106) and consecutive patients—moving backwards—from 28 February 2020 to 6 December 2019 (prepandemic group; N= 104). The primary outcome was the length of time between the end of surgery to readiness for hospital discharge. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), the need for postoperative analgesia, and the duration of stay in the postanesthesia care unit (PACU). Results: The median [interquartile range (IQR)] time to readiness for hospital discharge was significantly lower in patients who received paravertebral blocks for breast cancer surgery compared with GA (intrapandemic group, 119 [99–170] min vsprepandemic group, 191 [164–234] min; P< 0.001) as was the incidence of PONV (3% vs11%; P= 0.03) and median [IQR] PACU durations of stay (29 [21–39] min vs46 [37–63] min; P< 0.001). Conclusions: Patients who received paravertebral blocks for breast cancer surgery in the intrapandemic group were ready for hospital discharge earlier, spent less time in the PACU, and experienced less PONV than those who received GA in the prepandemic group. With growing surgical wait times, concerns related to aerosol-generating procedures, and recommendations to avoid GA when feasible, paravertebral blocks as the principal anesthetic modality for breast cancer surgery offered benefits for patients and medical teams.

Purpose: Hypotension is common following spinal anesthesia (SA) during elective Cesarean delivery (CD). Although common practice is to alleviate inferior vena cava (IVC) compression, limited evidence supports a 15° tilt for CD. We measured collapsibility of the IVC in supine and 15° left lateral tilt positions with ultrasound before and after SA and phenylephrine infusion in term parturients. Methods: Twenty term parturients scheduled for CD were recruited for this prospective study. Ultrasound measurements of the IVC were taken 1) supine before SA, 2) tilted 15° before SA, 3) supine after SA, and 4) tilted 15° after SA. A phenylephrine infusion was begun after injection of SA. The primary outcome was to evaluate the impact of position on the IVC collapsibility index (IVCCI): a measure of the difference between the maximum and minimum IVC diameter with respiration. Results: The mean (standard deviation) IVCCI (%) before SA was higher in the supine 19.5 (8.0) than in the tilted 15.0 (6.4) position (mean difference, 4.5; 95% confidence interval [CI], 0.1 to 8.9; P= 0.04). After SA, there was no significant difference between IVCCI (%) in the supine 17.8 (8.3) and tilted 14.2 (6.9) position (mean difference, 3.5; 95% CI, -0.9 to 7.9; P= 0.13). There was no correlation between the pre-spinal IVVCI measurements and the quantity of phenylephrine used during the surgery. Conclusion: The IVCCI was lower in the 15° tilt position than in the supine position, but not after SA with a phenylephrine infusion. Ultrasound imaging can help identify IVC compression. Trial registration: www.clinicaltrials.gov(NCT03410199); registered 18 January 2018.

Purpose: The effect of direct laryngoscopy using a Macintosh blade (MAC) vsGlideScope™ videolaryngoscopy using a Spectrum LoPro blade (GVL) on nociceptive stimulation has not been quantitatively studied. This study used the new nociception level (NOL) index to compare the nociceptive response induced by GVL or MAC during laryngoscopy with or without intubation. Methods: Patients underwent two laryngoscopies at four-minute intervals (L1, L2), one with GVL and the other with MAC (first randomization). A third laryngoscopy (L3) followed by tracheal intubation was performed four minutes after L2 (GVL or MAC, second randomization). Nociception was quantitatively assessed by NOL and standard hemodynamic parameters (heart rate [HR] and mean arterial pressure). For the crossover design, blade comparisons accounted for sequence and blade type. A possible carryover effect between laryngoscopies was assessed. Results: In the 50 patients randomized, there was no carryover effect from one laryngoscopy to the next for all analyzed parameters. Nociception level index peak values were higher with MAC than GVL. Analysis of ΔNOL showed a lower nociceptive response with GVL for L1+L2 combined. Mean peak NOL values were significantly higher after L3+intubation than after L1+L2, for both GVL and MAC groups. Analysis of ΔHR values did not show a significant difference between GVL and MAC for any laryngoscopy. Conclusion: Laryngoscopy alone with GVL induces less nociception than with MAC. The NOL was more sensitive than HR at detecting nociceptive responses to MAC vsGVL. Additionally, and irrespective of which technique/blade was used, the combination of laryngoscopy + tracheal intubation produced a much greater nociceptive response than the laryngoscopy alone. Trial registration: www.clinicaltrials.gov (NCT03277872); registered 29 August 2017.

In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.

Background: The Pain Monitoring Device (PMD) monitor (Medasense Biometrics Ltd., Ramat Gan, Israel) uses the Nociception Level (NOL) index, a multiple parameter-derived index that has recently shown a good sensitivity and specificity to detect noxious stimuli. The aim of this study was to assess the latest version of the device (PMD200TM) on variations of the NOL response after standardized tetanic stimuli to study the correlation between remifentanil doses and NOL. Methods: Data from 26 patients undergoing midline laparotomy and receiving a desflurane-remifentanil-based anesthetic coupled with low thoracic epidural analgesia were analyzed. A standardized tetanic stimulus was applied to the forearm of the patients at different remifentanil infusion rates. The primary aim was to evaluate the correlation between post-tetanic stimulation NOL values from the PMD200 and remifentanil doses. The NOL index variations after experimental and clinical stimuli were also compared with heart rate (HR), mean arterial pressure (MAP), and Bispectral Index™ (BIS). Results: A correlation between post-tetanic stimulation NOL values and remifentanil doses was found (r = −0.56; 95% confidence interval [CI], −0.70 to −0.44; P< 0.001). The NOL discriminated noxious from non-noxious states with the maximal Youden’s index value of the NOL receiver operating characteristic (ROC) curve showing a specificity of 88% (95% CI, 69.0 to 100) and sensitivity of 79.1% (95% CI, 56.2 to 95.5). The area under the NOL ROC curve (AUC, 0.9; 95% CI, 0.84 to 0.95) was significantly different from the other variables (P< 0.001 vsHR; P< 0.001 vsMAP; P< 0.001 vsBIS). Conclusions: The NOL value after noxious stimulus decreased with incremental remifentanil doses, showing a significant inverse correlation between the NOL index and opioid doses. The sensitivity and specificity of NOL to discriminate between noxious and non-noxious stimuli suggests its interesting potential as a monitor of nociception intensity during anesthesia. Trial registration: www.clinicaltrials.gov(NCT 02884778); 27 July, 2016.

Analgesia might be evaluated with simple changes in vital signs, a non-specific and non-sensitive method. Heart rate variability (HRV) correlates with autonomous nervous system activity and can be used to evaluate painful stimuli. Heart rate variability is then transformed into a numeric scale called the analgesia nociception index (ANI), where higher values represent predominant parasympathetic tone, thus low nociception. Under general anesthesia, the ANI decreases following painful stimuli and increases after administration of analgesia, but significant interindividual variability is present. The goal of the present study was to evaluate the ANI as a pain index in healthy awake volunteers. Following research ethics board approval, participants were positioned supine in a calm operating room. The participants’ vital signs and ANI were monitored. After evaluation of all parameters without any stimulation, 23 volunteers received a 2 Hz electrical stimulus at the wrist with increasing current intensity from 0–30 mA (5 mA increments). The current was kept constant for three minutes at each level, and the volunteers rated their pain on a numeric rating scale (NRS) every minute. The Pearson correlation coefficient and linear regression were used to analyze the relationship between the ANI and the NRS score. The ANI absolute values and the variations from baseline were both analyzed. There was a very weak negative correlation between the NRS score and ANImean(Pearson, -0.089; 95% confidence interval [CI], −0.192 to −0.014; P= 0.045) and between the NRS score and ∆ANImean(Pearson, −0.174; 95% CI, −0.272 to −0.072; P< 0.001; regression slope, −0.586; 95% CI, −0.930 to −0.243; P< 0.001). Heart rate, blood pressure, and respiratory rate did not vary significantly throughout the study. These findings provide little evidence to support use of the ANI in awake subjects or in awake patients such as those in the emergency room or in the intensive care unit. Nevertheless, based on an important difference between the expected correlation and the real correlation between the ANI and the NRS scores found in our results, the present study might be underpowered. Studies with a larger sample size would be required to enable firm conclusions about the clinical utility of the ANI in this population of awake volunteers as well as in awake patients. This study was registered with ClinicalTrials.gov (NCT02589093). L’analgésie peut être évaluée en observant de simples changements des signes vitaux, via une méthode non spécifique et non sensible. La variabilité de la fréquence cardiaque (HRV) est corrélée à l’activité du système nerveux autonome et peut être utilisée pour évaluer les stimuli douloureux. La variabilité de la fréquence cardiaque est ensuite transformée en une échelle numérique, l’indice ANI (pour analgesia nociception index), sur laquelle les valeurs plus élevées représentent un tonus parasympathique prédominant, soit une nociception moindre. Sous anesthésie générale, l’ANI diminue après des stimuli douloureux et augmente après l’administration d’une analgésie, mais il existe une importante variabilité interpersonnelle. L’objectif de cette étude était d’évaluer l’ANI en tant qu’indice de la douleur chez des volontaires sains éveillés. Après avoir reçu l’approbation du Comité d’éthique de la recherche, les participants ont été placés en décubitus dorsal dans une salle d’opération calme. Les signes vitaux et l’ANI des participants ont été monitorés. Après l’évaluation de tous les paramètres sans aucune stimulation, 23 volontaires ont reçu un stimulus électrique de 2 Hz au poignet avec une intensité de courant augmentant de 0 à 30 mA (en incréments de 5 mA). Le courant a été maintenu pendant trois minutes à chaque niveau, et les volontaires ont évalué leur douleur sur une échelle d’évaluation numérique (EEN) chaque minute. Le coefficient de corrélation de Pearson et la régression linéaire ont été utilisés pour analyser la relation entre l’ANI et le score sur l’EEN. Les valeurs absolues de l’ANI et les variations par rapport aux valeurs de base ont toutes deux été analysées. Il y a eu une très faible corrélation négative entre le score sur l’EEN et l’ANImean(Pearson, −0,089; intervalle de confiance [IC] 95%, −0,192 à −0,014; P= 0,045) et entre le score sur l’EEN et ∆ANImean(Pearson, −0,174; IC 95%, −0,272 à −0,072; P< 0,001; courbe de régression, −0,586; IC 95%, −0,930 à −0,243; P< 0,001). Il n’y a pas eu de variation significative de la fréquence cardiaque, de la tension artérielle et de la fréquence respiratoire tout au long de l’étude. Ces résultats ne sont pas suffisamment probants pour appuyer l’utilisation de l’ANI chez des sujets éveillés ou des patients éveillés tels que ceux de l’urgence ou de l’unité des soins intensifs. Toutefois, étant donné l’importante différence entre la corrélation anticipée et la corrélation véritable entre l’ANI et les scores sur l’EEN dans nos résultats, il est possible que notre étude manque de puissance. Des études portant sur un échantillon plus vaste seraient nécessaires pour parvenir à des conclusions définitives concernant l’utilité clinique de l’ANI chez cette population de volontaires éveillés ainsi qu’auprès de patients éveillés. Cette étude a été enregistrée au ClinicalTrials.gov, numéro NCT02589093.

This manuscript proposes pharmacological strategies that might decrease persistent postsurgical pain (PPSP). These recommendations are based on a review of current publications available in the literature. Persistent postsurgical pain has been defined by the International Association for the Study of Pain as clinical discomfort that lasts more than two months after surgery. Recent reviews reported that 10-50% of patients develop chronic pain after surgery, 2-10% with disabling chronic pain at six months. Preventive interventions should target all types of surgery, but specific attention should be placed on surgical insults that carry a high risk of pain chronicization. Regional anesthesia (RA) should be used whenever feasible, and a continuous perineural/epidural local anesthetic infusion is preferred over a single-shot technique. The RA should be initiated prior to the surgical incision and then continued for at least 24-72 hr after the surgery. Perioperative opioids should be used for nociceptive stimuli not managed by the RA. An intravenous infusion of ketamine, an N-methyl-D-aspartate receptor (NMDA) antagonist, might be added for a further decrease in neuronal sensitization, especially when the procedure is extensive or when RA is not feasible or contraindicated. A multimodal approach is always suggested. The literature still does not strongly support the use of gabapentinoids for PPSP prevention; however, they might be maintained in patients who use them preoperatively. A winning strategy to reduce the incidence of PPSP may well involve performing minimally invasive surgery, providing adequate perioperative analgesia based on RA, and using a multimodal approach with NMDA antagonists. Ce manuscrit, basé sur la littérature, propose des stratégies pharmacologiques qui pourraient réduire les douleurs chroniques postchirurgicales (DCPC). Les DCPC ont été définies par l’International Association for the Study of Pain(IASP) comme un inconfort clinique qui dure plus de deux mois après la chirurgie. Des revues récentes de la littérature ont rapporté que 10 à 50 % des patients manifestent des DCPC, 2 à 10 % étant des DCPC handicapantes après six mois postopératoires. Des interventions préventives devraient cibler tous les types de chirurgie, mais une attention spécifique devrait être portée aux chirurgies qui sont associées à un haut risque de DCPC. L’anesthésie locorégionale (ALR) devrait être utilisée autant que possible en l’absence de contre-indication. Une perfusion continue périneurale/péridurale d’anesthésiques locaux est préférable à une injection unique. Elle devrait être amorcée avant l’incision chirurgicale puis maintenue pour au moins 24-72 h après chirurgie. Les opioïdes périopératoires devraient être utilisés pour traiter les stimuli nociceptifs non couverts par l’ALR. Une perfusion intraveineuse de kétamine pourrait être ajoutée pour réduire encore plus la sensibilisation neuronale, spécialement quand la procédure est importante ou quand l’ALR est contre-indiquée ou non réalisable. Une approche multimodale est bien sûr toujours recommandée. La littérature n’appuie pas particulièrement l’utilisation des gabapentinoïdes pour prévenir les DCPC. Cependant ils seraient à maintenir chez les patients qui les utilisent déjà en préopératoire. Le recours à des techniques chirurgicales minimalement invasives, l’utilisation d’une analgésie périopératoire basée sur l’ALR, une approche multimodale et les antagonistes N-méthyl-D-aspartate devraient constituer une stratégie permettant une réduction de l’incidence des DCPC.