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Objective Data on chronic pain after lung transplantation are heterogeneous. This study prospectively explored the prevalence, characteristics, consequences, and preoperative predictors of pain in lung transplant recipients. Design A prospective cohort study. Setting The Foch University Hospital, Suresnes, France. Participants Patients registered on the waiting list for double-lung transplantation in the authors’ institution from August 2008 to October 2013 and transplanted. Interventions Database prospectively completed in real time during consultations with a pain-certified anesthesiologist before lung transplantation and six months after surgery. Measurements and Main Results The assessments explored pain in three components: physical (intensity, location, neuropathic and sensory qualifications, treatments), mental (anxiety and depression), and quality of life. Seventy-two patients underwent all assessments. The prevalence of six-month postoperative pain was 68.0%. Among patients with pain, 83.3% reported mild average pain and 26.5% had neuropathic pain. All patients who responded to the questionnaire took analgesics frequently, but only 9.1% took opioids. Patients with pain reported higher levels of anxiety (p = 0.02) and depression (p = 0.01). Additionally, they presented with increased difficulty in ambulation (p = 0.03), work (p = 0.02), and sleep (p = 0.02). The maximum level of preoperative pain was an independent risk factor of six-month postoperative pain (p = 0.03). Conclusions The authors report a high prevalence of chronic pain with concomitant psychosocial repercussions despite a reported mild intensity. Perioperative measures, such as personalized and detailed management plans, could improve patient satisfaction.

Background The questionnaire from Ringsted et al. (RQ) assesses the consequences on daily activities of a post–thoracotomy pain syndrome. Our study aimed at translating the RQ into French and to validate its metrological properties. Methods Four months after thoracotomy, 134 patients participating in a prospective comparative study of two surgical thoracotomy approaches (axillary and posterolateral) scored the translated questionnaire. The sensitivity of this version was assessed by comparing scores from patients complaining of pain to that of non-complainers. Concurrent validity was assessed using ratings from direct questions on pain, mood, anxiety and enjoyment of life. Homogeneity was assessed with Crombach's coefficient and dimensionality with PCA. Results A scoring system was devised to homogenise pain-related impairment with activities that were never performed before surgery and activities that had to be abandoned due to pain. The French version is bi-dimensional: routine activities (carrying heavy loads, raising the arms above the head, housework, getting out of bed, car driving, lying on the operated side, coughing, sitting for half an hour) are opposed to running, walking 1 km, climbing stairs, bending knees, standing for half an hour, swimming and cycling; both these factors contribute independently to the global score. Global and factor scores are sensitive to presence of pain while direct questions account for 20 to 50 % of the information provided by the questionnaire. Conclusion The French version of the RQ is suitable to assess chronic repercussions of lung surgery on the ability of patients to perform their daily activities.

Few studies have clarified the use of complementary therapies (CTs) in France. The main objective of this preliminary study was to evaluate knowledge of CTs in 4 representative groups of patients: patients suffering from cancer, patients presenting with a chronic noncancerous disease, chronic dialysis patients and nonchronic or cancerous patients needing surgery.A formalized questionnaire was designed by 2 psychologists, an oncologist and an anesthesiologist in charge of the Pain Clinic and Support Care Unit. One-hundred eleven patients were enrolled, and all agreed to complete the questionnaire.Eighty (72%) patients did not know the term "complementary therapies" (patients who were "not aware of CTs"), and 24 (21.6%) patients knew the term "complementary therapies" (patients who were "aware of CTs"), while 7 patients were not sure of the meaning. There were no differences between aware and unaware patients in gender (P = .27), age (P = .24), level of education (p = 0.24) or professional occupation (P = .06). Knowledge about CTs was significantly different among the different categories of patients (P = .03), with the only statistically significant difference between groups being between oncologic patients receiving ambulatory chemotherapy and patients presenting with a chronic noncancerous disease (P = .004).This preliminary study clearly highlights that patients and health caregivers are not aware of CTs and that there is a need for better communication about CTs.

Background Hypnosis has a positive effect on peri-operative anxiety and pain. Objective The objective of this study was to assess the impact of a formal deep hypnosis session on the consumption of propofol for anaesthetic induction using automated administration of propofol guided by the bispectral index (BIS) in a closed loop. Design A 1 : 1 randomised, usual-care-controlled, single-centre trial. Setting Tertiary care centre in France from April 2014 to December 2015. Patients Female adult patients scheduled for outpatient gynaecological surgery under general anaesthesia. Intervention Before surgery, patients were randomised to receive either a deep hypnosis session or routine care. Anaesthetic induction was performed automatically by propofol without opioids and was assisted by the BIS in a closed loop. Main outcome measures The primary endpoint was the propofol dose required for anaesthesia induction, defined as a BIS less than 60 for at least 30 s. Results Data for 31 patients in the hypnosis group and 35 in the control group were analysed. There was no evidence of a difference in the mean required propofol dose for anaesthetic induction between the hypnosis and the control groups (2.06 mg kg (95% confidence interval [1.68 to 2.43]) versus 1.79 mg kg (95% CI [1.54 to 2.03]), P = 0.25, respectively). Conclusion The current study, which was designed to determine the effect of a deep hypnosis session on anaesthesia induction using an automated tool for propofol administration, failed to detect a difference in the required dose of propofol. Trial registration ClinicalTrials.gov, NCT02249364.

Supplemental Digital Content is available in the text, Background: Thoracic epidural analgesia is associated with a high rate of postoperative urine retention (POUR). Auriculotherapy can reduce visceral dysfunction and can be helpful in anesthesiology and pain control. The aim of this study was to test the efficacy of preoperative auriculotherapy to decrease the occurrence of POUR. Methods: This single-center, double-blinded, 2-arm randomized study was performed between January 2015 and May 2016 in a tertiary care university hospital. Male patients scheduled for an elective lung surgical procedure under combined general anesthesia and thoracic epidural analgesia were included. Auriculotherapy (A group) was performed once the patient was under general anesthesia with 5 semi-permanent needles inserted in both ears at the “Shen Men” “bladder”, “pelvic parasympathetic”, “anterior hypothalamus”, and “frontal lobe” points. Five small round patches of adhesive pads were positioned bilaterally at the same points in the control group (C group). The main outcome measure was the requirement for bladder catheterization during the day and the first night following surgery. Results: Fifty-three patients were randomized and 25 analyzed in each group. Requirement for bladder catheterization was different between groups: 24 C group patients (96%) and 18 A group patients (72%) (P = .049, Fisher exact test; Odds Ratio = 0.11 [0.01–0.95]. The number of patients needed to treat with auriculotherapy to avoid 1 case of bladder catheterization was 4. No adverse effect was observed due to auriculotherapy. Conclusion: This study demonstrates that auriculotherapy is a safe and useful technique reducing POUR in thoracotomy patients benefiting from thoracic epidural analgesia. Trial registration: Clinicaltrials.gov identifier: NCT 02290054 (November 13, 2014).

Objective To report the major complications (epidural hematoma and abscess) of postoperative thoracic epidural analgesia in patients who underwent lung surgery. Design Prospective, monocentric study. Setting A university hospital. Participants All lung surgical patients who received postoperative thoracic epidural analgesia between November 2007 and November 2015. Interventions Thoracic epidural analgesia for patients who underwent lung surgery. Measurements and Main Results During the study period, data for 2,907 patients were recorded. The following 3 major complications were encountered: 1 case of epidural hematoma (0.34 case/1,000; 95% confidence interval 0.061-1.946), for which surgery was performed, and 2 cases of epidural abscesses (0.68 case/1,000; 95% confidence interval 0.189-2.505), which were treated medically. Conclusions The risk range of serious complications was moderate; only the patient who experienced an epidural hematoma also experienced permanent sequelae.

Background Intraoperative transesophageal echocardiographic visualization of the vascular anastomosis of lung grafts can be difficult. The goal of this prospective study was to compare intraoperative transesophageal echocardiography and contact ultrasound. Methods Vessel imaging and Doppler analysis obtained before chest closure by both techniques were compared in 18 bilateral lung transplant recipients. Results Twenty-four arteries in 36 and 45 pulmonary veins in 72 were recorded using transesophageal echocardiography versus 34 and 60 by contact ultrasound ( p = 0.05). Views of the left pulmonary artery ( p = 0.04) and of the left superior and inferior pulmonary veins ( p = 0.04 and p = 0.02, respectively) were more often obtained with contact ultrasound. Measurements of vessel diameters were similar by both methods except for the left superior vein, which was smaller by the transesophageal approach ( p = 0.002). In 1 patient, inferior venous diameters could not be obtained by either method. Nine arterial and 47 venous velocities were recorded by transesophageal echocardiography versus 21 and 33 by contact ultrasound ( p = 0.001). Contact ultrasound produced better left pulmonary artery recordings ( p = 0.02), whereas transesophageal echocardiography was more effective on venous velocities. Left inferior vein velocity was twofold higher using transesophageal echocardiography ( p Conclusions These results suggest clinicians should exercise caution when making treatment decisions when using transesophageal echocardiography alone.

Supplemental Digital Content is available in the text, Background: Transcutaneous electrical nerve stimulation (TENS) is often used for the treatment of low-back pain (LBP). However, its effectiveness is controversial. Objective: To determine the efficacy of TENS in the treatment LBP when associated to a therapeutic education program (TEP). Design: Open randomized monocentric study. Setting: University hospital between 2010 and 2014. Patients: A total of 97 patients suffering from LBP. Interventions: Routine care (TENS group) or routine care plus a therapeutic education program (TENS-TEP group) based on consultation support by a pain resource nurse. Main outcome measures: EIFEL and Dallas Pain Questionnaire scores. Results: Twenty-two patients (44%) were still assessable at the end-of-study visit, whereas 33 (70%) were assessable at the same time point in the TENS-TEP group (P = .013). The EIFEL score and the Dallas score had a similar evolution over time between groups (P = .18 and P = .50 respectively). Similarly, there were no significant differences between the groups with respect to resting pain scores (P = .94 for back pain and P = .16 for leg pain) and movement pain scores (P = .52 for back pain and P = .56 for leg pain). At Month 6, there was no significant difference between the groups (P = .85) with regard to analgesics and social impact. Two patients presented a serious adverse event during the study (one in each group) but non-attributable to the treatment studied. Conclusion: This study does not support the use of TENS in the treatment of patients with chronic LBP even though patients benefited from a therapeutic education program by a pain resource nurse. However, the higher number of premature withdrawals in the TENS group may be due to early withdrawal of patients who did not experience improvement of their symptoms.

Resume L’existence d’un foramen ovale permeable (FOP) est une entite frequente chez les patients susceptibles d’etre anesthesies. Lors du passage en ventilation controlee, le FOP peut provoquer une hypoxemie ou induire un risque d’embolie pulmonaire paradoxale. Le FOP doit etre recherche systematiquement en cas de neurochirurgie en position assise ou d’intervention sur le rachis cervical comportant un risque d’embolie gazeuse. D’autres interventions sont egalement a risque sans que la recherche systematique ne soit recommandee. Le diagnostic de FOP repose essentiellement sur l’echographie preoperatoire avec injection de produit de contraste et manœuvre de Valsalva. Les patients ayant un FOP et un risque eleve d’embolie peroperatoire doivent etre monitores avec un catheter veineux central auriculaire, un moniteur de profondeur d’anesthesie et beneficier en preventif de techniques qui augmentent la pression veineuse (remplissage vasculaire). Le diagnostic d’embolie repose sur la chute de la valeur du CO2 expire. Si le diagnostic de FOP est connu, il faut discuter de sa fermeture en fonction du risque embolique inherent a la chirurgie.

Objective: To determine if propofol infusion can be steered automatically by using bispectral index (BIS) as a controller during lung transplantation. Design: A prospective study of patients undergoing lung transplantation. Setting: University hospital. Participants: Twenty consecutive patients scheduled for bilateral (n = 14) or single (n = 6) lung transplantation. Interventions: The goal of the closed-loop administration of propofol was to maintain the BIS value between 40 and 60 during the maintenance phase. The remifentanil infusion was adjusted according to standard clinical practice. Measurements and Main Results: The closed-loop system was able to provide anesthesia maintenance for all patients. Cardiopulmonary bypass was used in 5 patients, and 14 patients received a thoracic epidural catheter. The BIS value was maintained between 40 and 60 during 84% ± 16% of the maintenance phase. Eleven patients were extubated in the operating room, and 1 patient needed reintubation. Conclusion: Closed-loop control of consciousness by a computer during lung transplantation is clinically feasible.

Objective The automated administration of propofol in a closed loop could be used to objectively evaluate the nonpharmacological anesthetic action of hypnotherapy. The objective of this study was to evaluate the impact of a conversational hypnosis session on the consumption of propofol for anesthetic induction. Design A randomized, usual care-controlled, single-center, patient-blind trial. Setting Tertiary care center in France from November 2012 to December 2013. Participants Adult patients scheduled for a surgical procedure under general anesthesia. Interventions Before surgery, patients were randomized with a computer-generated random list for a preoperative conversational hypnosis session or for usual care. The conversational hypnosis session was conducted and individualized by the therapist with an academic degree in hypnosis in a quiet environment. Anesthetic induction was automatically performed by propofol without opioids and was assisted by the bispectral index in a closed loop. Outcome Primary endpoint was the propofol dose required for anesthesia induction, defined as a Bispectral index less than 60 for at least 30 seconds. Results The study included 48 patients in the hypnosis group and 49 patients in the control group. No difference in propofol consumption to obtain anesthesia induction was observed between the groups (total dose: 138.6 [67.5] and 130 [47.9] mg, P = .47; adjusted dose: 2.15 [1.09] and 1.95 [0.66] mg/kg, P = .28, for the hypnosis and control groups, respectively). Hetero-evaluation of arm movement during propofol injection (no reaction: 98% and 74%; P = .004, in the hypnosis and control groups, respectively) and face reaction at venous access placement (no reaction 59% and 30%; P = .017, in the hypnosis and control groups, respectively) were lower in the hypnosis group. No adverse event was reported. Conclusions No difference in propofol consumption was observed in this study designed to evaluate the effect of a hypnotic conversational session on anesthesia induction using an automated tool for propofol administration.

Context Pain in patients awaiting lung transplantation is not well known. Objectives This study prospectively investigated prevalence and characteristics of pain in these patients. Methods Assessment, undertaken at the time of registration, comprised an interview, a physical examination by a pain-qualified anesthesiologist, and a questionnaire completed by the patient and investigator. This questionnaire included evaluation of pain (intensity, location, sensory and affective qualifications, and treatment), detection of neuropathic pain, and assessment of anxiety and depression. A patient was considered "with pain" when at least one of the following criteria was met: 1) positive answer to the question "Do you suffer regularly from pain?" and 2) score greater than 3 on at least one of three numeric pain scales (current, maximal, and average during the last eight days) ranging from 0 (no pain) to 10 (most severe pain imaginable). Results One hundred forty-three patients were enrolled. Prevalence of pain was 59%. Three independent variables were correlated to the magnitude of the average pain score for the preceding eight days: female gender ( P = 0.003), cystic fibrosis ( P = 0.02), and depression score ( P = 0.02). Among the pain patients, 39% took analgesic drugs daily and 36% regularly but less than daily; 2% used opioids. Nineteen percent used nonpharmacological strategies (e.g., hypnosis, relaxation). Conclusion This study highlights the prevalence of pain in this population and specific problems associated with pain such as anxiety and depression. Appropriate assessment and treatment of pain should be considered a component of pretransplantation management.

Objective: To determine the usefulness of systematic intraoperative transesophageal echocardiography in a cardiac surgical unit. Design: Open prospective observational survey. Setting: University Hospital. Participants: Consecutive adult patients (n = 203) undergoing elective or urgent cardiac operations. Measurements and Main Results: Pre—cardiopulmonary bypass imaging yielded unsuspected findings in 26 patients (12.8%) and changed the planned surgery in 22 patients (10.8%). Transesophageal echocardiography modified the diagnosis in eight patients (17%) operated on for mitral valvulopathy, in seven patients (15.5%) with aortic valvular disease, in four patients (4.6%) with coronary artery disease, in five patients operated on for thoracic aorta diseases regardless of their localization (18.5%), and in two miscellaneous cases. On the basis of the data obtained from the transesophageal echocardiography carried out at the end of cardiopulmonary bypass, an immediate reintervention was required in five cases (2.5%). Conclusions: It is concluded that systematic intraoperative transesophageal echocardiography significantly affected decision making in this cardiac surgical unit. Its routine use in all cardiac surgical patients is recommended.

Background In patients after lung transplantation, dysfunction of pulmonary venous and artery anastomoses leading to reoperation is described. Methods and results Pulmonary artery and vein anastomoses were evaluated intraoperatively by monoplane transesophageal echocardiography (TEE) in 18 patients undergoing lung transplantation (nine right, five left single lung transplantations, and four bilateral transplantations). All 13 right pulmonary artery anastomoses and all 22 pulmonary vein anastomoses could be visualized by TEE. None of the nine left pulmonary anastomoses could be visualized. Of the 13 right pulmonary anastomoses, 12 were considered normal, their diameter ranging from 1 to 1.7 cm (mean, 1.26±0.24 cm). A moderate stenosis of one pulmonary artery anastomosis was identified but did not require reoperation. Of the 22 pulmonary vein anastomoses, 16 were considered normal, their diameter being >0.5 cm and the peak systolic flow velocity ≤1 m/s at the location of the anastomoses. In five cases, the anastomoses were not considered normal, but reoperation was not indicated. In one case, a severe stenosis of pulmonary vein associated with graft dysfunction led to an early reoperation. Conclusion Intraoperative TEE during lung transplantation contributes to the immediate evaluation of pulmonary vein and right pulmonary artery anastomoses and allows immediate surgical correction. Further investigations are necessary to establish threshold values requiring reoperation.

Objectives The primary goal of this study was to investigate the incidence of chronic pain 1 year after a thoracotomy. Secondary goals were to determine which interventions and patient characteristics were associated with reports of chronic pain, to identify risk factors, to clarify the neuropathic component, and to determine the impact of chronic pain on daily life. Methods All 86 patients, who had undergone a posterolateral thoracotomy at our institution between October 2007 and March 2008, received a questionnaire 1 year after the surgical procedure and were contacted by phone 1 week later. Results Sixty-five patients responded. Prevalence of chronic pain was 48%; among them 8 patients had neuropathic pain (12% of the whole group). Current, average, and maximal pain scale scores were 1.1±1.2, 1.3±1.3, and 3.4±1.7 (visual analog scale), respectively. Patients with chronic pain were about 10 years younger (P=0.07) and had a significantly less severe American Society of Anesthesiologists (ASA) score (29% grade I versus 17%, P=0.04). With regard to risk factors, age and ASA score were negatively correlated with chronic pain whereas number of drains was positively correlated to it. In most patients with pain (84%), activities of daily life were affected. Discussion Chronic pain is common after thoracotomy and its neuropathic component is infrequent. As age, ASA scores, number of drains, and situations relating to daily life seem to play a role in pain occurrence, a multifaceted approach against the onset of chronic pain is advisable.

Bilateral lung transplantation (BLT) is a recently described procedure based on two sequential single-lung transplantations (SLT), which are performed by a transverse sternobithoracotomy. It does not require either cardiac arrest or routine use of cardiopulmonary bypass (CPB). The intraoperative management of 10 patients suffering from end-stage pulmonary disease is reported. Implantation of the first graft is quite similar to a SLT. Problems encountered during this procedure (ie, hypoxemia, hypercapnia, or low cardiac output) were due to restricted pulmonary and cardiac reserve. Preoperative and intraoperative assessment of the recipient's respiratory and cardiac status was, therefore, of prime importance. Mild preoperative pulmonary hypertension, well-preserved right ventricular function, and removal of the less well-perfused lung limited these difficulties; no patient required partial CPB at this stage. During the second lung implantation, gas exchange was provided by the first grafted lung. Measurements of pulmonary vascular resistance (PVR), venous admixture (Qva/Qt), and dead space (VD/VT) assessed with the arterial-to-end-tidal CO2 difference were used to confirm the adequacy of perfusion and V/Q matching. In one patient, partial CPB was instituted because of surgical difficulty related to inadequate size matching of the lungs. In the other patients, first graft function was satisfactory and the second graft was implanted without CPB. With chest closure, PVR returned to nearly normal values (range, 57-293, mean 167 dynes.s.cm-5) and Qva/Qt increased (range, 3 to 36, mean 20%). This limited series demonstrates that CPB is optional during this procedure. Good selection of recipients and donors, good lung preservation methods, and a short duration of cold ischemia are essential to success.

Introduction: Ischaemic injury of the hand following radial artery cannulation although rarely reported is a severe complication. One mechanism of injury is radial artery thrombosis in the absence of adequate ulnar collateral circulation. Allen test is usually performed before a radial artery cannulation. Recently, some authors have proposed the registration of a finger pulse oximetric signal after compression of the radial artery to assess the collateral circulation in the handl. The aim of our study is to compare Allen modified test (AT)* and pulse oxymetry (PO)3 to Doppler ultrasound (DU) considered as the reference method. Patients and Nethods: After approval of our Ethical Commitee, fifty consecutive ASA II-IV patients undergoing CABG or major vascular surgery (34 males / 16 females, age ranged from 26 to 76, mean = 59.2 yrs) gave their informed consent and were tested preoperatively by three investigators. Each investigator performed always the same test and was not aware of the other investigators findings. The first hand tested (right or left) was randomly assigned. A directional 8 MGHZ DU flow probe (DUH 800) was used to assess the functionality of the superficial palmar arch: the collateral circulation was classified in: good (DU+), poor or absent (DU-). Results of AT were classified according to the time of full palmar blush (FPB) after release of the ulnar compression: < 7 set, 7s FPB< 15 set, FPB 5 15 sec. Finger probe of a pulse oxymeter (Nellcor 200) was placed on the thumb and the pulse oximetric signal was registered; after compression of radial artery at the wrist the presence (PO+) or absence (PO-) of signal was recorded. Results: The superficial palmar arch was functional in 89/100 hands at the DU. When AT was compared to DU (Tab.l), AT showed a sensibility of 0.86 and a specificity of 0.54 (PPV = 0.93, NPV = 0.33) when the time accepted to observe a FPB was limited to < 7 sec. When this time increased to < 15 sec., sensibility of AT became 0.99 and specificity 0.27 (PPV = 0.91, NPV = 0.75); consequently, the risk of considering normal collateral circulation according to AT when it was absent, according to DU, increased from 0.46 to 0.73 when time of PBF was increased. When PO was compared to DU (Tab 2), PO showed a sensibility of 0.89 and a specificity of 0.45 (PPV = 0.93, NPV = 0.38). The probability to have a PO+ with a DUwas 0.55. Conclusion: AT and PO do not seem to be accurate in assessing collateral circulation in the hand in patients undergoing major cardiovascular surgery.