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Parmi les interruptions de grossesse pour raison médicale (IMG), le nombre des IMG tardives (2eet 3etrimestre, après 14 semaines) reste stable. Ces procédures engendrent une douleur physique sévère avec une composante émotionnelle importante. Malgré cette évidence, les publications dédiées à l’analgésie de ces patientes sont peu fréquentes. Alors que les IMG du 3etrimestre bénéficient d’une analgésie obstétricale classique, il n’y a actuellement pas de consensus concernant la prise en charge analgésique optimale des IMG réalisées entre 14 et 23 semaines. L’analgésie péridurale pourrait être utilisée plus fréquemment tant pour son efficacité à soulager les douleurs viscérales du travail que pour son utilité lors d’une éventuelle révision utérine (20 % de rétention placentaire). L’analgésie intraveineuse auto-contrôlée par la parturiente reste une alternative intéressante. Les traitements non pharmacologiques semblent très peu utilisés et leur efficacité peu étudiée alors qu’ils pourraient être utiles dans une prise en charge plus personnalisée. Étant donné la complexité du vécu douloureux des parturientes, l’utilisation de scores mesurant uniquement l’intensité de la douleur est insuffisante. Si plusieurs études rapportent une mémorisation fréquente de la douleur expérimentée lors des IMG tardives, la récupération (quality of recovery) post-IMG est rarement évaluée. En conclusion, il est nécessaire de développer des outils appropriés pour mieux évaluer, et de là améliorer, la qualité de la prise en charge globale (y compris analgésique) des patientes pendant les IMG tardives.

L’utilisation périopératoire des opiacés n’est pas anodine et conditionne la récupération postopératoire des patients (récupération fonctionnelle, douleur persistante, consommation d’analgésiques opiacés à long terme). Les anesthésistes ont été pointés du doigt mais il s’agit en réalité d’une responsabilité partagée. La réduction de l’utilisation des opiacés en périopératoire constitue un important défi. C’est une opportunité unique de réflexion et d’optimisation de la prise en charge périopératoire des patients dans lesquels les anesthésistes ont un important rôle éducatif à jouer (tant envers les patients que les soignants). L’utilisation de techniques d’anesthésie balancée est recommandée avec une réduction maximale des doses en intraopératoire d’opiacés de synthèse et un choix judicieux des molécules utilisées. Le développement en cours d’outils de monitorage de la nociception intraopératoire devrait permettre d’atteindre ces objectifs. En post-opératoire, l’utilisation d’une analgésie balancée et l’éducation des patients sont impératives. Le recours à des services dits de « douleur transitionnelle » peut s’avérer nécessaire chez certains patients pour prévenir une utilisation à long terme des opiacés prescrits dans le décours de la chirurgie. Certaines molécules semblent particulièrement addictogènes (tramadol, oxycodone), surtout chez des patients prédisposés (tabac, alcool, benzodiazépines). L’optimisation de l’utilisation des opiacés en périopératoire inclut également la gestion de la prise d’opiacés en préopératoire qui concerne environ un quart des patients. Ces opiacés, même ceux dits « faibles », sensibilisent le système nerveux central et ont un impact négatif sur la récupération postopératoire.

Le contrôle de l’analgésie à domicile est un des défis actuels de l’anesthésie et au sens large de la médecine périopératoire. Ce défi est d’autant plus important que les durées d’hospitalisation sont de plus en plus courtes avec l’essor de la chirurgie ambulatoire et de la RAAC. Il véhicule également des enjeux socio-économiques importants qui dépassent le côté humain et éthique de la prise en charge analgésique des patients. Plusieurs pistes d’amélioration du contrôle de la douleur à domicile ont été soulevées, à commencer par une amélioration des connaissances concernant le vécu du patient et la douleur dite « sub-aiguë » lors du retour à domicile ou du séjour en revalidation. Une meilleure application des connaissances actuelles concernant l’analgésie périopératoire (éducation des soignants) et le développement de techniques et de services dédicacés à l’éducation et au suivi personnalisé du patient s’avèrent incontournables pour évoluer.

Depuis la mise en évidence des douleurs chroniques post-chirurgie (DCPC), les études cliniques rétrospectives et prospectives n’ont pas cessé de questionner la valeur prédictive de la douleur postopératoire (DPO) aiguë. Il semble cependant que le lien DPO-DCPC soit loin d’être évident et probablement ne soit pas un lien de causalité. Bien que l’intensité et la durée de la DPO soient des facteurs de risque reconnus, de nombreux patients endurent encore actuellement une DPO sévère mais ne vont pas développer pour autant de DCPC. Ces observations soulignent les limites actuelles de l’évaluation et de la compréhension de la DPO aiguë. Parmi l’évolution et les progrès dans ce domaine, l’utilisation des trajectoires de douleur, qui mettent en évidence le caractère dynamique de la DPO, a permis une meilleure approche de sa résolution. De plus, l’observation du fait que le lien entre DPO-DCPC ne soit pas nécessairement un continuum a souligné l’importance et la valeur prédictive de la douleur dite « sub-aiguë ou douleur transitionnelle » dans le développement des DCPC. En résumé, une approche différente de la douleur aiguë (c.-à.-d, au-delà des scores d’intensité) qui prend en considération le patient dans sa globalité et dans son devenir (douleur sub-aiguë) est peut-être la clé d’une meilleure prédiction et donc d’une prévention plus efficace des douleurs chroniques post-chirurgie.

Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications.

AimsLow haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery.Patients and MethodsAll consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery.ResultsWe included 829 patients; the mean age was 81 years (sd11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01).ConclusionOur results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into account in perioperative management.Cite this article: Bone Joint J2019;101-B:1122–1128.

Opioids are the most potent drugs used to control severe pain. However, neuroadaptation prevents opioids' ability to provide long-term analgesia and produces opposite effects, i.e., enhancement of existent pain and facilitation of chronic pain development. Neuroadaptation to opioids use results in the development of two interrelated phenomena: tolerance and “opioid-induced hyperalgesia” (OIH). Tolerance, a pharmacologic concept, and OIH, a clinical syndrome, have been mostly observed under experimental conditions in animals and in human volunteers. In contrast, their occurrence and relevance in clinical practice remain debated. In perioperative setting, intraoperative administration of high doses of opioids increases postoperative opioid requirements and worsens pain scores (acute tolerance or perioperative OIH). Further, preoperative chronic opioid intake and postoperative long-term use of opioid analgesics beyond the normal healing period have a negative effect on surgical outcome. Conversely, observations of improved patient's recovery after opioid-sparing anesthesia techniques stand as an indirect evidence that perioperative opioid administration deserves caution. To date, perioperative OIH has rarely been objectively assessed by psychophysics tests in patients. A direct relationship between the presence of perioperative OIH and patient outcome is missing and certainly deserves further studies.

Post-operative pain management protocols may be optimised by examining procedure-specific evidence and outcomes. This recognition led to the formation of the PROcedure-SPECific Pain ManagemenT (PROSPECT) collaboration of anaesthesiologists and surgeons. The aim of PROSPECT is to provide practical and evidence-based recommendations to prevent and treat post-operative pain after specific surgical procedures, thereby overcoming the limitations of generic, non-specific guidelines. Updates in the methodology of PROSPECT in 2017 have placed an increased emphasis on the clinical relevance of studies, including a focus on interventions in the context of multimodal analgesia strategies and consideration of risks and benefits of interventions in specific surgical settings. Evidence-based reviews of analgesic measures, including advice on surgical techniques and adjuvants after diverse surgical procedures, have been completed by the PROSPECT collaboration and are accessible on the website (www.postoppain.org) and published in the peer-reviewed literature. These reviews continue to identify significant gaps in clinically relevant research on post-operative analgesia and are possibly leading to a closing of some of these gaps.

Chronic postsurgical pain (CPSP) has become a health priority and is scheduled to be included in the upcoming version of the International Classification of Diseases, 11th Revision (ICD-11). Recent studies on CPSP show unchanged prevalence despite progress made in fundamental research about underlying pathophysiological mechanisms. Nevertheless, clinical research has allowed better understanding of some CPSP aspects such as the development of neuropathic CPSP. Actually, some improvements are ongoing such as a refined definition and the assessment of CPSP in vulnerable populations, for example, paediatric patients. Pain after surgery, its resolution or its transition to CPSP is a dynamic process that reinforces the necessity of longitudinal assessment and management. In other words, CPSP can be called ‘perioperative medicine’.

Étudier l’incidence, les caractéristiques et facteurs de risque des douleurs chroniques postcésariennes (DCPC) à l’hôpital Yalgado. Un questionnaire était administré par appel téléphonique à 204 patientes aux sixième, neuvième et douzième mois après une césarienne. Les questions portaient sur la présence de douleurs cicatricielles, leurs caractéristiques et leurs répercussions sur la vie des patientes. L’enrôlement s’est fait durant la consultation du 45e jour postopératoire, a duré deux mois, et les données cliniques, chirurgicales et anesthésiques étaient recueillies rétrospectivement. Le questionnaire de suivi de la douleur leur a été expliqué pendant l’enrôlement, puis ultérieurement administré par le même enquêteur. Après une analyse descriptive de la population étudiée avec Epi Info version 3.3.1, une comparaison des patientes avec et sans DCPC était effectuée afin de mettre en évidence les facteurs de risque. Sur 204 patientes incluses, 113 (55,4 %) ont terminé l’étude et 91 patientes ont été perdues de vue. Au total, 72 femmes (63,7 %) ont rapporté des DCPC à un moment ou l’autre de leur suivi. Les perdues de vue étaient comparables aux patientes suivies. La fréquence des DCPC diminuait au fil du temps, passant de 63,7 % à six mois (15,2 % de douleur modérée à sévère) à 52,21 % au neuvième mois et 38,9 % au 12e mois (4,5 % de douleur modérée à sévère). Le jeune âge (OR: 1,48, p= 0,002), l’antécédent de césarienne (OR: 2,94; p= 0,01), les chirurgiens en formation (OR: 4,15, p= 0,05), l’incision Pfannenstiel (OR: 5,96, p= 0,001), l’anesthésie générale (OR: 3,21, p= 0,03) sont les facteurs de risque associés à des DCPC, alors que la rachianesthésie (OR: 0,4, p= 0,009) protégeait contre la DCPC. L’intensité médiane était de 1,7 au sixième mois, de 1,03 au neuvième mois et de 0,85 au 12e mois. La douleur était modérée dans 51,38 % des cas au sixième mois contre 18,18 % au 12e mois. La douleur était intermittente (59,7 %) ou permanente (16,6 %) au sixième mois versus respectivement 86,3 et 4,5 % au 12emois. L’intensité de la douleur diminuait dans le temps. La majorité des femmes (89,2 %) s’automédiquaient, et 3,2 % ont présenté des troubles du sommeil. Les DCPC sont fréquentes dans notre série et souffrent d’un manque de prise en charge médicale. To study the incidence, characteristics and risk factors of chronic post-Caesarean pain (CPCP) at Yalgado Hospital. A survey was conducted via telephone of 204 patients at 6, 9 and 12 months after a Caesarean section. The questions focused on the presence of scar pain, its characteristics and the subsequent repercussions on patients’ lives. Enrolment was carried out during the postoperative day 45 consultation; it lasted for two months and clinical, surgical and anaesthetic data was collected retrospectively. The pain follow-up questionnaire was explained during enrolment, then subsequently delivered by the same person. After a descriptive analysis of the population studied was conducted with ÉpiInfo™ version 3.3.1, a comparison of patients with and without CPCP was made in order to highlight any risk factors. Of the 204 patients included, 113 (55.4%) completed the study and 91 patients were lost to follow-up. A total of 72 women (63.7%) reported CPCP at one point or another during their follow-up. The patients lost to follow-up were comparable to those who received follow-up. The frequency of CPCP decreased over time, falling from 63.7% at 6 months (15.2% had moderate to severe pain) to 52.21% at month 9 and 38.9% at month 12 (4.5% with moderate to severe pain). Young age (OR: 1.48, P= 0.002), previous Caesarean (OR: 2.94, P= 0.01), trainee surgeons (OR: 4.15, P= 0.05), a Pfannenstiel incision (OR: 5.96, P= 0.001), and general anaesthesia (OR: 3.21, P= 0.03) are risk factors associated with CPCP, whereas spinal anaesthesia (OR: 0.4, P= 0.009) protected against CPCP. The median pain intensity was 1.7 at month 6, 1.03 at month 9 and 0.85 at month 12. The pain was moderate for 51.38% at month 6, compared with 18.18% at month 12. Pain was intermittent (59.7%) or permanent (16.6%) at month 6, versus 86.3% and 4.5% respectively at month 12. The intensity of the pain decreased over time. The majority of the women (89.2%) self-medicated, and 3.2% had sleep-related difficulties. CPCP is a common experience in our series, and suffers from a lack of medical care.

Total knee arthroplasty (TKA) is a major orthopaedic intervention. The length of a patient's stay has been progressively reduced with the introduction of enhanced recovery protocols: day-case surgery has become the ultimate challenge.This narrative review shows the potential limitations of day-case TKA. These constraints may be social, linked to patient’s comorbidities, or due to surgery-related adverse events (e.g. pain, post-operative nausea and vomiting, etc.). Using patient stratification, tailored surgical techniques and multimodal opioid-sparing analgesia, day-case TKA might be achievable in a limited group of patients. The younger, male patient without comorbidities and with an excellent social network around him might be a candidate.Demographic changes, effective recovery programmes and less invasive surgical techniques such as unicondylar knee arthroplasty, may increase the size of the group of potential day-case patients. The cost reduction achieved by day-case TKA needs to be balanced against any increase in morbidity and mortality and the cost of advanced follow-up at a distance with new technology. These factors need to be evaluated before adopting this ultimate ‘fast-track’ approach. Cite this article: Bone Joint J2015;97-B(10 Suppl A):40–4.

The patient with a painful arthritic knee awaiting total knee arthroplasty (TKA) requires a multidisciplinary approach. Optimal control of acute post-operative pain and the prevention of chronic persistent pain remains a challenge. The aim of this paper is to evaluate whether stratification of patients can help identify those who are at particular risk for severe acute or chronic pain. Intense acute post-operative pain, which is itself a risk factor for chronic pain, is more common in younger, obese female patients and those suffering from central pain sensitisation. Pre-operative pain, in the knee or elsewhere in the body, predisposes to central sensitisation. Pain due to osteoarthritis of the knee may also trigger neuropathic pain and may be associated with chronic medication like opioids, leading to a state of nociceptive sensitisation called ‘opioid-induced hyperalgesia’. Finally, genetic and personality related risk factors may also put patients at a higher risk for the development of chronic pain. Those identified as at risk for chronic pain would benefit from specific peri-operative management including reduction in opioid intake pre-operatively, the peri-operative use of antihyperalgesic drugs such as ketamine and gabapentinoids, and a close post-operative follow-up in a dedicated chronic pain clinic.Cite this article: Bone Joint J2015;97-B(10 Suppl A):45–8.

Tout type de chirurgie est susceptible de donner des douleurs chroniques post-chirurgie (DCPC), y compris les procédures dites « mineures ».

Although childbirth is considered a natural event, some deliveries may necessitate instrumentation or surgical intervention. In contrast with trauma or surgery, persistent pain after delivery has received little attention until recently, despite the large number of individuals potentially at risk.

The persistence of pain after surgical procedure or trauma has become a major focus of interest and its prevention now represents a challenge as an indicator of quality of healthcare. The only way to develop effective strategies to prevent the development of chronic pain is to better understand the mechanisms involved in the progression from acute to chronic pain, with the aim to target high-risk patients and to adapt perioperative management.

Recent advances in the understanding of postoperative pain have demonstrated its association with sensitization of the central nervous system (CNS) which clinically elicits pain hypersensitivity. N-methyl-d-aspartate (NMDA) receptors play a major role in synaptic plasticity and are specifically implicated in CNS facilitation of pain processing. Therefore, NMDA receptor antagonists, and specifically ketamine commonly used in clinical practice, have been implicated in perioperative pain management. At subanesthetic (i.e. low) doses, ketamine exerts a specific NMDA blockade and hence modulates central sensitization induced both by the incision and tissue damage and by perioperative analgesics such as opioids. However, the mechanisms underlying ketamine anti-hyperalgesic effect are not totally understood, and neither is the relationship between central sensitization and the risk of developing residual pain after surgery. This chapter examines the role of low doses of ketamine as an adjuvant drug in current perioperative pain management and questions the anti-hyperalgesic mechanisms involved.

Incisional pain remains underevaluated and undermanaged while evidence is growing that perioperative treatments strongly influence patients' outcome. The present review examines the recent developments in mechanisms underlying perioperative pain and questions current understanding of incisional pain features observed in patients.

The management of postoperative pain after cesarean section slightly differs from that of the general surgical population, specifically women need to recover quickly to take care of their newborn baby. Optimal pain management is imperative for the success of immediate-term and long-term rehabilitation and this principle applies to obstetric patients. There is growing evidence that perioperative pain management has consequences extending well beyond the immediate recovery period. Unrelieved postoperative pain is a striking risk factor for the development of residual pain.

We investigated whether intraoperative ‘subanesthetic doses’ of ketamine have a postoperative anti-hyperalgesic and an analgesic effect and which is the preferential route of administration, either systemic (intravenous, i.v.) or epidural. One hundred patients scheduled for rectal adenocarcinoma surgery under combined epidural/general anesthesia were included. Before skin incision all the patients received an epidural bolus followed by an infusion of continuous bupivacaine/sufentanil/clonidine mixture. They were randomly assigned to receive no ketamine (group 1), i.v. ketamine at the bolus dose of 0.25 mg/kg followed by an infusion of 0.125 mg/kg per h (group 2), 0.5 mg/kg and 0.25 mg/kg per h (group 3), epidural ketamine 0.25 mg/kg and 0.125 mg/kg per h (group 4), or 0.5 mg/kg and 0.25 mg/kg per h (group 5). All i.v. and epidural analgesics were stopped at the end of surgery and patients were connected to an i.v. morphine patient-controlled analgesia (PCA) device. Short-term postoperative analgesia (72 h) was assessed by pain visual analog scale scores at rest, cough, and movements as well as by PCA requirements. Wound mechanical hyperalgesia was evaluated and residual pain was assessed by asking the patients at 2 weeks, and 1, 6, and 12 months. The area of hyperalgesia and morphine PCA requirements were significantly reduced in group 3. These patients reported significantly less residual pain until the sixth postoperative month. These observations support the theory that subanesthetic doses of i.v. ketamine (0.5 mg/kg bolus followed by 0.25 mg/kg per h) given during anesthesia reduce wound hyperalgesia and are a useful adjuvant in perioperative balanced analgesia. Moreover, they show that the systemic route clearly is the preferential route.

Purpose: To show the use of the short acting opioid remifentanil for labour analgesia when epidural analgesia is considered to be contraindicated.

The second generation of tissue expanding prostheses is the permanent expander. It has been used in a series of 88 breast reconstructions following mastectomy for malignant and premalignant disease in 49 secondary and 39 primary reconstructions, the longest follow-up being 45 months and the shortest 12 months. Pre- and postoperative radiotherapy (45 gy) has been the major source of complications: implant loss (11%), infection (2%); capsular contracture-Baker's grade III–IV (90%); and, improper positioning should also be mentioned. Primary reconstruction is no longer performed if postoperative radiotherapy is scheduled. The results were totally different if radiotherapy was omitted after primary reconstruction. The expansion was smooth, an attractive breast shape with mild ptosis was easily achieved, and only minor complications were encountered. A permanent tissue expander, either alone or covered with a latissimus dorsi flap, remains our first choice in breast reconstruction.

L’hépatectomie partielle pour donation vivante apparentée adulte-pédiatrique a des conséquences importantes en termes de douleur aiguë et chronique. Partant du constat fait par Bonnet et al. en 2012 [1]sur la douleur ressentie en postopératoire de cette chirurgie aux cliniques universitaires Saint-Luc (CUSL, Bruxelles), nous avons revu notre protocole anesthésique en le basant sur des données probantes. Nous rapportons ici les résultats de l’application de ce protocole.

Background. Opioid-induced hyperalgesia has been demonstrated in awake animals. We observed an increased haemodynamic reactivity in response to noxious stimuli in rats under sevoflurane anaesthesia treated with a very low dose of sufentanil. The aim of this investigation was to determine whether the two phenomena share a common origin: an opioid-induced excitatory reaction. To address this, we administered several drugs with proven efficacy in opioid hyperalgesia to rats presenting with haemodynamic hyper-reactivity. Methods. The MACbar of sevoflurane was measured in controls and in animals treated with sufentanil 0.005 µg kg−1 min−1 before and after administration of i.v. (0.25, 0.5 mg kg−1) and intrathecal (i.t.) (250 µg) ketamine, i.v. (0.5, 1 mg kg−1) and i.t. (30 µg) MK-801(NMDA antagonist), i.v. (0.1, 0.5 mg kg−1) naloxone, i.v. (10 mg kg−1) and i.t. (50, 100 µg) ketorolac or i.t. (100, 150 µg) meloxicam (COX-2 inhibitor). Results. Sufentanil 0.005 µg kg−1 min−1 significantly increased MACbar (3.2 (sd 0.3) versus 1.9 (0.3) vol%). With the exception of naloxone, all drugs displayed a significant MACbar-sparing effect (>50%) in controls. Naloxone completely prevented haemodynamic hyperactivity. Two patterns of reaction were recorded for the other drugs: either hyper-reactivity was suppressed and the MACbar-sparing effect was maintained (i.t. ketamine, i.t. MK-801, i.t. ketorolac [100 µg], i.t. meloxicam [150 µg]) or hyper-reactivity was blocked but MACbar-sparing effect was lost (i.v. ketamine [0.5 mg kg−1], i.v. MK-801 [0.5, 1 mg kg−1], i.v. ketorolac [10 µg kg−1], i.t. ketorolac [50 µg], i.t. meloxicam [100 µg]). Conclusions. We have demonstrated that low-dose sufentanil-induced haemodynamic hyper-reactivity is an excitatory µ-opiate-related phenomenon. This effect is reversed by drugs effective in treating opiate-induced hyperalgesia.