+

Correction du PBLD d'octobre 2012

+Quelques remarques

n  Le respect des consignes n  Bibliographie

n  Date de remise

n  Exactement la même réponse que …

n  Lire ce qui est écrit …

n  Réponse personnelle sur le cas

n  Résultats n  102 réponses

n  Moyenne : 12,3/20

+

0

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73 76 79 82 85 88 91 94 97 100

+Cas clinique

n  Une femme de 32 ans, 58 Kg, 169 cm, vient en consultation en vue d’une tympanoplastie de l’oreille droite.

n  Dans ses antécédents, vous notez une amygdalectomie dans l’enfance avec reprise pour hémostase à J6.

n  Vous ne relevez pas d’autres antécédents et son traitement médicamenteux consiste en un contraceptif oral.

n  A l’examen clinique vous auscultez un souffle systolique 1/6 d’allure fonctionnelle.

+ Question 1 : Allez-vous demander des examens complémentaires chez cette patiente ? Si oui, le(s)quel(s) ? Justifiez brièvement

n  Existe-t-il des recommandations ?

n  Pas d’examens systématiques

n  Examens orientés en fonction de l’anamnèse, l’examen clinique et le type de chirurgie

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

Preoperative evaluation of the adult patient undergoingnon-cardiac surgery: guidelines from the European Societyof AnaesthesiologyStefan De Hert, Georgina Imberger, John Carlisle, Pierre Diemunsch, Gerhard Fritsch, Iain Moppett,Maurizio Solca, Sven Staender, Frank Wappler and Andrew Smith, the Task Force on PreoperativeEvaluation of the Adult Noncardiac Surgery Patient of the European Society of Anaesthesiology

The purpose of these guidelines on the preoperative evaluationof the adult non-cardiac surgery patient is to presentrecommendations 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 perioperativeperiod may constitute an increased risk of morbidity andmortality, aside from the risks associated with the underlyingdisease. Second, this should help us to design perioperativestrategies that aim to reduce additional perioperative risks. Veryfew well performed randomised studies on the topic areavailable and many recommendations rely heavily on expertopinion and are adapted specifically to the healthcare systems inindividual countries. This report aims to provide an overview ofcurrent knowledge on the subject with an assessment of thequality of the evidence in order to allow anaesthetists all overEurope to integrate – wherever possible – this knowledge intodaily patient care. The Guidelines Committee of the EuropeanSociety of Anaesthesiology (ESA) formed a task force with

members of subcommittees of scientific subcommittees andindividual members of the ESA. Electronic databases weresearched from the year 2000 until July 2010 without languagerestrictions. These searches produced 15 425 abstracts.Relevant systematic reviews with meta-analyses, randomisedcontrolled trials, cohort studies, case–control studies andcross-sectional surveys were selected. The ScottishIntercollegiate Guidelines Network grading system was used toassess the level of evidence and to grade recommendations.The final draft guideline was posted on the ESA website for4 weeks and the link was sent to all ESA members, individual ornational (thus including most European national anaesthesiasocieties). Comments were collated and the guidelinesamended as appropriate. When the final draft was complete, theGuidelines Committee and ESA Board ratified the guidelines.Eur J Anaesthesiol 2011;28:684–722

Published online 14 September 2011

Appendix 1 and 2 are accessible on the European Journalof Anaesthesiology website: http://links.lww.com/EJA/A22.

PREAMBLEThe purpose of these guidelines is to present recommen-dations based on available relevant clinical evidence onthe topic. The information comes not only from high-quality randomised clinical trials or meta-analysesbut also from cohort studies and even expert opinionstatements. Ultimately, these recommendations should

help physicians in the decision making in their clinicalpractice.

Clinical practice over Europe varies widely. The way inwhich healthcare services are organised and specificnational jurisprudence may have a significant impacton how this scientific evidence will be implemented inthe various European countries, despite the availability ofthe same scientific information. For instance, a Dutchstudy in 4540 adult surgical patients suggested thattrained nurses were perfectly capable of assessing thepreoperative health status of surgical patients as com-pared with anaesthesiologists, thereby providing scienti-fic basis for a potential place for nurses in the preoperativeassessment of patients.1 Yet, in a number of Europeancountries nurses are not legally allowed to perform pre-operative evaluations of patients. Hence, this particularscientific information might result in a recommendation

GUIDELINES

From the Department of Anaesthesiology, Ghent University Hospital, GhentUniversity, Ghent, Belgium (SDH), Cochrane Anaesthesia Review Group,Rigshospitalet, Copenhagen, Denmark (GI), Department of Anaesthesia andPeri-operative Medicine, Torbay Hospital, Torquay, Devon, UK (JC), Serviced’Anesthesie Reanimation Chirurgicale, Hopital de Hautepierre, UniversityHospital of Strasbourg, Strasbourg, France (PD), Department ofAnaesthesiology, Peri-operative Medicine and Intensive Care Medicine,Paracelsus Medical University, Salzburg, Austria (GF), Division of Anaesthesiaand Intensive Care, University of Nottingham, Nottingham, UK (IM), Department ofAnaesthesiology, Azienda Ospedaliera di Melegnano, Milan, Italy (MS),Department of Anaesthesiology and Intensive Care, Spital Mannedorf,Mannedorf, Switzerland (SS), Department of Anaesthesiology and OperativeIntensive Care Medicine, University Hospital Witten/Herdecke, Cologne,Germany (FW) and Department of Anaesthesiology, University of Lancaster,Lancaster, UK (AS)

Correspondence to Stefan De Hert, MD, PhD, Professor of Anaesthesiology,Department of Anaesthesiology, Ghent University Hospital, Ghent University, DePintelaan 185, B-9000 Ghent, BelgiumTel: +32 9 332 3281; fax: +32 9 332 4987; e-mail: stefan.dehert@ugent.be

This article is accompanied by the following InvitedCommentary:

Riad W, Chung F. Continent-wide anaesthesiaguideline: a step towards safer practice. Eur J Anaes-thesiol 2011; 28:682–683.

0265-0215 ! 2011 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e3283499e3b

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

Preoperative evaluation of the adult patient undergoingnon-cardiac surgery: guidelines from the European Societyof AnaesthesiologyStefan De Hert, Georgina Imberger, John Carlisle, Pierre Diemunsch, Gerhard Fritsch, Iain Moppett,Maurizio Solca, Sven Staender, Frank Wappler and Andrew Smith, the Task Force on PreoperativeEvaluation of the Adult Noncardiac Surgery Patient of the European Society of Anaesthesiology

The purpose of these guidelines on the preoperative evaluationof the adult non-cardiac surgery patient is to presentrecommendations 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 perioperativeperiod may constitute an increased risk of morbidity andmortality, aside from the risks associated with the underlyingdisease. Second, this should help us to design perioperativestrategies that aim to reduce additional perioperative risks. Veryfew well performed randomised studies on the topic areavailable and many recommendations rely heavily on expertopinion and are adapted specifically to the healthcare systems inindividual countries. This report aims to provide an overview ofcurrent knowledge on the subject with an assessment of thequality of the evidence in order to allow anaesthetists all overEurope to integrate – wherever possible – this knowledge intodaily patient care. The Guidelines Committee of the EuropeanSociety of Anaesthesiology (ESA) formed a task force with

members of subcommittees of scientific subcommittees andindividual members of the ESA. Electronic databases weresearched from the year 2000 until July 2010 without languagerestrictions. These searches produced 15 425 abstracts.Relevant systematic reviews with meta-analyses, randomisedcontrolled trials, cohort studies, case–control studies andcross-sectional surveys were selected. The ScottishIntercollegiate Guidelines Network grading system was used toassess the level of evidence and to grade recommendations.The final draft guideline was posted on the ESA website for4 weeks and the link was sent to all ESA members, individual ornational (thus including most European national anaesthesiasocieties). Comments were collated and the guidelinesamended as appropriate. When the final draft was complete, theGuidelines Committee and ESA Board ratified the guidelines.Eur J Anaesthesiol 2011;28:684–722

Published online 14 September 2011

Appendix 1 and 2 are accessible on the European Journalof Anaesthesiology website: http://links.lww.com/EJA/A22.

PREAMBLEThe purpose of these guidelines is to present recommen-dations based on available relevant clinical evidence onthe topic. The information comes not only from high-quality randomised clinical trials or meta-analysesbut also from cohort studies and even expert opinionstatements. Ultimately, these recommendations should

help physicians in the decision making in their clinicalpractice.

Clinical practice over Europe varies widely. The way inwhich healthcare services are organised and specificnational jurisprudence may have a significant impacton how this scientific evidence will be implemented inthe various European countries, despite the availability ofthe same scientific information. For instance, a Dutchstudy in 4540 adult surgical patients suggested thattrained nurses were perfectly capable of assessing thepreoperative health status of surgical patients as com-pared with anaesthesiologists, thereby providing scienti-fic basis for a potential place for nurses in the preoperativeassessment of patients.1 Yet, in a number of Europeancountries nurses are not legally allowed to perform pre-operative evaluations of patients. Hence, this particularscientific information might result in a recommendation

GUIDELINES

From the Department of Anaesthesiology, Ghent University Hospital, GhentUniversity, Ghent, Belgium (SDH), Cochrane Anaesthesia Review Group,Rigshospitalet, Copenhagen, Denmark (GI), Department of Anaesthesia andPeri-operative Medicine, Torbay Hospital, Torquay, Devon, UK (JC), Serviced’Anesthesie Reanimation Chirurgicale, Hopital de Hautepierre, UniversityHospital of Strasbourg, Strasbourg, France (PD), Department ofAnaesthesiology, Peri-operative Medicine and Intensive Care Medicine,Paracelsus Medical University, Salzburg, Austria (GF), Division of Anaesthesiaand Intensive Care, University of Nottingham, Nottingham, UK (IM), Department ofAnaesthesiology, Azienda Ospedaliera di Melegnano, Milan, Italy (MS),Department of Anaesthesiology and Intensive Care, Spital Mannedorf,Mannedorf, Switzerland (SS), Department of Anaesthesiology and OperativeIntensive Care Medicine, University Hospital Witten/Herdecke, Cologne,Germany (FW) and Department of Anaesthesiology, University of Lancaster,Lancaster, UK (AS)

Correspondence to Stefan De Hert, MD, PhD, Professor of Anaesthesiology,Department of Anaesthesiology, Ghent University Hospital, Ghent University, DePintelaan 185, B-9000 Ghent, BelgiumTel: +32 9 332 3281; fax: +32 9 332 4987; e-mail: stefan.dehert@ugent.be

This article is accompanied by the following InvitedCommentary:

Riad W, Chung F. Continent-wide anaesthesiaguideline: a step towards safer practice. Eur J Anaes-thesiol 2011; 28:682–683.

0265-0215 ! 2011 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e3283499e3b

+

Sur base de l’anamnèse

n  Hémorragie post-opératoire à J6 après amygdalectomie dans l’enfance nécessitant une reprise pour hémostase

n  Est-ce une anamnèse hémostatique positive ?

n  Score hémorragique

+

Points

Symptômes 0 1 2 3

Epistaxis Non ou insignifiant Oui Méchage / cautérisation

Transfusion

Peau Non ou insignifiant Pétéchies Hématomes Motif de consultation

Saignements lors des blessures mineures

Non ou insignifiant

Oui (1-5 épisodes par an)

Motif de consultation

Chirurgie d’hémostase

Cavité orale Non ou insignifiant

Oui Motif de consultation

Chirurgie / transfusion

Système digestif Non ou insignifiant

Oui

Motif de consultation

Chirurgie / transfusion

Extraction dentaire Non ou insignifiant

Oui

Suture / hémostase locale

Transfusion

Chirurgie Non ou insignifiant

Oui

Ré-intervention Transfusion

Ménorragies Non ou insignifiant

Oui

Consultation, pilule, fer

Chirurgie / transfusion

Hémorragie du post-partum Non ou insignifiant

Oui (substitution en fer)

Transfusion, curetage

Hystérectomie

Hématomes musculaires Non ou insignifiant

Oui

Motif de consultation

Chirurgie / transfusion

Hémarthroses Non ou insignifiant

Oui

Motif de consultation

Chirurgie / transfusion

Score hémorragique n  Score > 3 chez l’homme

n  Score > 5 chez la femme

+ Quels examens demander si l’anamnèse hémorragique est positive ?

n  Bilan d’orientation n  Formule sanguine :

n  Hémoglobine n  Plaquettes

n  Tests de base de la coagulation sanguine : n  TCA n  Temps de prothrombine n  Temps de thrombine n  Fibrinogène

n  Si ces tests sont négatifs : n  Si suspicion clinique forte à consultation d’hémostase où on évaluera

l’hémostase primaire et la fonction plaquettaire, hyperfibrinolyse, facteur XIII

n  Si ces tests sont positifs : n  Consultation d’hémostase et dosages des facteurs XI,VIII,IX

+

Sur base de l’examen clinique

n  Souffle systolique d’allure fonctionnelle n  Intervalle entre B1 et le début du souffle

n  Souffle crescendo-decrescendo

n  Se termine avec le composant correspondant à B2

n  Augmentation de la rapidité du flux sanguin à travers un orifice valvulaire normal n  Causes de souffle systolique fonctionnel:

n  Stress

n  Anémie

n  Grossesse

n  Thyrotoxicose

n  Aortique :HTA, BAV complet

n  Pulmonaire : Shunt G/D sur CIA

n  Faut-il n  un ECG ? n  une échocardiographie ? n  un dosage de l’hémoglobine ? n  un test de grossesse ? n  un dosage TSH , T3-T4 ?

+

Non-invasive testingPre-operative non-invasive testing aims at providinginformation on three cardiac risk markers: LV dysfunc-tion, myocardial ischaemia, and heart valve abnormal-ities, all major determinants of adverse post-operativeoutcome. LV function is assessed at rest, and variousimaging modalities are available. For myocardial ischae-mia detection, exercise ECG and non-invasive imagingtechniques may be used. The overall theme is that thediagnostic algorithm for risk stratification of myocardialischaemia and LV function should be similar to thatproposed for patients in the non-surgical setting withknown or suspected IHD.47 Non-invasive testing shouldnot only be considered for coronary artery revasculari-zation but also for patient counselling, change of peri-operative management in relation to type of surgery,anaesthetic technique, and long-term prognosis. Echo-cardiography is preferred for evaluation of valve disease(see section on specific diseases, subheading valvularheart disease).

Non-invasive testing of cardiac disease

ElectrocardiographyThe 12-lead ECG is commonly performed as part of pre-operative cardiovascular risk assessment in patientsundergoing non-cardiac surgery. In IHD patients, thepre-operative electrocardiogram contains important prog-nostic information and is predictive of long-term outcomeindependent of clinical findings and perioperative ischae-mia.48 However, the electrocardiogram may be normal ornon-specific in a patient with either ischaemia or infarc-tion. The routine use of ECG prior to all types of surgeryis a subject of increasing debate. A retrospective studyinvestigated 23 036 patients scheduled for 28 457 surgicalprocedures; patients with abnormal ECG findings had agreater incidence of cardiovascular death than those withnormal ECG results (1.8% vs. 0.3%). In patients whounderwent low-risk or low- to intermediate-risk surgery,the absolute difference in the incidence of cardiovasculardeath between those with and without ECG abnormal-ities was only 0.5%.49

Recommendations on ECG

Assessment of left ventricular functionResting LV function can be evaluated before non-cardiacsurgery by radionuclide ventriculography, gated singlephoton emission computed tomography (SPECT) ima-ging, echocardiography, magnetic resonance imaging(MRI), or multislice computed tomography (CT), withsimilar accuracy.50 Routine echocardiography is notrecommended for the pre-operative evaluation of LVfunction, but may be performed in asymptomatic patientsundergoing high-risk surgery. A meta-analysis of theavailable data demonstrated that an LV ejection fractionof <35% had a sensitivity of 50% and a specificity of 91%for prediction of perioperative non-fatal MI or cardiacdeath.51 The limited predictive value of LV functionassessment for perioperative outcome may be related tothe failure to detect severe underlying IHD. Recommen-dations for the pre-operative evaluation of (asympto-matic) patients with cardiac murmurs are discussed inthe section on VHD.

Recommendations on resting echocardiography

Non-invasive testing of ischaemic heart diseasePhysiological exercise using a treadmill or bicycle erg-ometer is the preferred method for detection of ischaemia.Physiological exercise provides an estimate of functionalcapacity, provides blood pressure and heart rate response,and detects myocardial ischaemia through ST-segmentchanges. The accuracy of exercise ECG varies significantlyamong studies. Meta-analysis of the reported studies usingtreadmill testing in vascular surgery patients showed arather low sensitivity (74%, 95% CI 60–88%) and speci-ficity (69%, 95% CI 60–78%), comparable with dailyclinical practice.51 The positive predictive value was aslow as 10%, but the negative predictive value was very high(98%). However, risk stratification with exercise is notsuitable for patients with limited exercise capacity dueto their inability to reach an ischaemic threshold. Further-more, pre-existing ST-segment abnormalities, especiallyin the pre-cordial leads V5 and V6 at rest, hamper reliableST-segment analysis. A gradient of severity in the testresult relates to the perioperative outcome: the onset of amyocardial ischaemic response at low exercise workloadsis associated with a significantly increased risk of peri-operative and long-term cardiac events. In contrast, theonset of myocardial ischaemia at high workloads is associ-ated with significantly less risk.30 Pharmacological stresstesting with either nuclear perfusion imaging or echocar-diography is more suitable in patients with limited physicalcapabilities.

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery 101

Recommendations Classa Levelb

Pre-operative ECG is recommended for patients who haverisk factor(s) and are scheduled for intermediate- orhigh-risk surgery

I B

Pre-operative ECG should be considered for patientswho have risk factor(s) and are scheduled for low-risksurgery

IIa B

Pre-operative ECG may be considered for patientswho have no risk factor and are scheduled forintermediate-risk surgery

IIb B

Pre-operative ECG is not recommended for patientswho have no risk factor and are scheduled forlow-risk surgery

III B

ECG, electrocardiography. a Class of recommendation. b Level of evidence.

Recommendations Classa Levelb

Rest echocardiography for LV assessment should beconsidered in patients undergoing high-risk surgery

IIa C

Rest echocardiography for LV assessment inasymptomatic patients is not recommended

III B

LV, left ventricular. a Class of recommendation. b Level of evidence.

Once the aetiology of post-operative heart failure isdiagnosed, treatment is similar to the non-surgical set-ting. Patients with heart failure have a significantly higherrisk of hospital readmission after surgical procedures.This confirms the need for careful discharge planningand close follow-up, optimally using a multidisciplinaryapproach.

Arterial hypertensionIn general, the presence of arterial hypertension is notconsidered to be an independent risk factor for cardio-vascular complications in non-cardiac surgery. Pre-operative evaluation allows the identification of patientswith hypertension, enables a search for target organdamage and evidence of associated cardiovascular path-ology to be undertaken, and allows initiation of appro-priate therapy. This is particularly important for thosewith concomitant risk factors.

There is no clear evidence favouring one mode of anti-hypertensive therapy over another in patients undergoingnon-cardiac surgery. Patients with arterial hypertensionshould be managed according to existing ESC Guide-lines.143 However, in hypertensive patients with conco-mitant IHD who are at high risk of cardiovascular com-plications, perioperative administration of b-blockers isrecommended. In patients with hypertension, antihyper-tensive therapy should be continued up to the morning ofsurgery and restarted promptly in the post-operativeperiod.144 In patients with grade 1 or 2 hypertension,143

there is no evidence that delay in surgery in order tooptimize therapy is beneficial. In these cases, antihyper-tensive medications should be continued during theperioperative period. In patients with grade 3 hyperten-sion (systolic blood pressure 180 mmHg and/or diastolicblood pressure 110 mmHg), the potential benefits ofdelaying surgery to optimize the pharmacological therapyshould be weighed against the risk of delaying thesurgical procedure.20,144

Valvular heart diseasePatients with VHD are at higher risk of perioperativecardiovascular complications during non-cardiac sur-gery.124 Echocardiography should be performed inpatients with known or suspected VHD, to assess itsseverity and consequences. On the basis of existing data,the following recommendations are particularly applicablein these patients.20,124

Recommendation on VHD

Aortic stenosisAortic stenosis (AS) is the most common VHD in Europe,particularly among the elderly.145 Severe AS (defined asaortic valve area <1 cm2, <0.6 cm2/m2 body surface area)constitutes a well-established risk factor for perioperativemortality and MI.146 In the case of urgent non-cardiacsurgery in patients with severe AS, such proceduresshould be performed under haemodynamic monitor-ing.124 In the case of elective non-cardiac surgery, thepresence of symptoms is a key for decision making.

In symptomatic patients, aortic valve replacement shouldbe considered before elective surgery. In patients who arenot candidates for valve replacement due to either highrisks associated with serious co-morbidities or those whorefuse, non-cardiac surgery should be performed only if isessential. In these patients, balloon aortic valvuloplasty ortranscatheter valve implantation may be a reasonabletherapeutic option before surgery.124,147

In asymptomatic patients, non-cardiac surgery of low tointermediate risk can be safely performed. If high-risksurgery is planned, further clinical assessment is necess-ary for aortic valve replacement. In those at high risk foraortic valve replacement, elective surgery under stricthaemodynamic monitoring should be performed only ifstrictly needed. In the remaining patients, aortic valvereplacement should be considered as the initial pro-cedure.124

Mitral stenosisNon-cardiac surgery can be performed at relatively lowrisk in patients with non-significant mitral stenosis (MS)(valve area >1.5 cm2) and in asymptomatic patients withsignificant MS (valve area<1.5 cm2) and systolic pulmon-ary artery pressure <50 mmHg. Pre-operative surgicalcorrection of MS in these patients is not indicated. Itneeds to be remembered that control of heart rate isessential to avoid tachycardia, which may cause pulmon-ary oedema. Strict control of fluid overload is also import-ant. Also development of AF may cause serious clinicaldeterioration.20,124 With the high risk of embolism, anti-coagulation control is important. In asymptomatic patientswith significant MS and systolic pulmonary artery pressure>50 mmHg and in symptomatic patients, the risk relatedto the non-cardiac procedure is significantly higher, andthese patients may benefit from percutaneous mitral com-missurotomy (or open surgical repair) particularly beforehigh-risk surgery.20,124

Aortic regurgitation and mitral regurgitationNon-significant aortic regurgitation (AR) and mitralregurgitation (MR) do not independently increase therisk of cardiovascular complications during non-cardiacsurgery. In asymptomatic patients with severe AR andMR (detailed classification presented in the ESC Guide-lines124) and preserved LV function, non-cardiac surgery

Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery 117

Recommendation Classa Levelb

In the presence of severe VHD it is recommended that aclinical and echocardiographic evaluation be performedand, if needed, treatment before non-cardiac surgery

I C

VHD, valvular heart disease. a Class of recommendation. b Level of evidence.

Guidelines for pre-operative cardiac risk assessment andperioperative cardiac management in non-cardiac surgery

The Task Force for Preoperative Cardiac Risk Assessment andPerioperative Cardiac Management in Non-cardiac Surgery ofthe European Society of Cardiology (ESC) and endorsed by theEuropean Society of Anaesthesiology (ESA)

Authors/Task Force Members: Don Poldermans (Chairperson) (The Netherlands), Jeroen J. Bax(The Netherlands), Eric Boersma (The Netherlands), Stefan De Hert (The Netherlands),Erik Eeckhout (Switzerland), Gerry Fowkes (UK), Bulent Gorenek (Turkey), Michael G. Hennerici (Germany),Bernard Iung (France), Malte Kelm (Germany), Keld Per Kjeldsen (Denmark), Steen Dalby Kristensen (Denmark),Jose Lopez-Sendon (Spain), Paolo Pelosi (Italy), Francois Philippe (France), Luc Pierard (Belgium),Piotr Ponikowski (Poland), Jean-Paul Schmid (Switzerland), Olav F.M. Sellevold (Norway), Rosa Sicari (Italy),Greet Van den Berghe (Belgium) and Frank Vermassen (Belgium)

92 ESC guidelines

Correspondence to Don Poldermans, Department of Surgery, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsTel: +31 10 703 4613; fax: +31 10 436 4557; e-mail: d.poldermans@erasmusmc.nl

The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. Nopart of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.

Disclaimer: The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Healthprofessionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, over-ride the individual responsibility ofhealth professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary thepatient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

Additional Contributors: Sanne E. Hoeks (The Netherlands); Ilse Vanhorebeek(Belgium)

ESC Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson) (France), Angelo Auricchio(Switzerland), Jeroen J. Bax (The Netherlands), Claudio Ceconi (Italy), Veronica Dean (France), GerasimosFilippatos (Greece), Christian Funck-Brentano (France), Richard Hobbs (UK), Peter Kearney (Ireland), TheresaMcDonagh (UK), Keith McGregor (France), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem(Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Panos Vardas (Greece), Petr Widimsky (CzechRepublic)

Document Reviewers: Raffaele De Caterina (CPG Review Coordinator) (Italy), Stefan Agewall (Norway), NawwarAl Attar (France), Felicita Andreotti (Italy), Stefan D. Anker (Germany), Gonzalo Baron-Esquivias (Spain), GuyBerkenboom (Belgium), Laurent Chapoutot (France), Renata Cifkova (Czech Republic), Pompilio Faggiano (Italy),Simon Gibbs (UK), Henrik Steen Hansen (Denmark), Laurence Iserin (France), Carsten W. Israel (Germany), RanKornowski (Israel), Nekane Murga Eizagaechevarria (Spain), Mauro Pepi (Italy), Massimo Piepoli (Italy), HansJoachim Priebe (Germany), Martin Scherer (Germany), Janina Stepinska (Poland), David Taggart (UK), MarcoTubaro (Italy)

European Journal of Anaesthesiology 2010, 27:92–137

Republished with permission from Eur Heart J. 2009; 22:2769–2812

The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines

Keywords: anaesthesiology, neurological disease, non-cardiac surgery, perioperative cardiac management, post-operative cardiac surveillance,pre-operative cardiac risk assessment, pre-operative cardiac testing, pre-operative coronary artery revascularization, pulmonary disease, renaldisease

Guidelines for pre-operative cardiac risk assessment andperioperative cardiac management in non-cardiac surgery

The Task Force for Preoperative Cardiac Risk Assessment andPerioperative Cardiac Management in Non-cardiac Surgery ofthe European Society of Cardiology (ESC) and endorsed by theEuropean Society of Anaesthesiology (ESA)

Authors/Task Force Members: Don Poldermans (Chairperson) (The Netherlands), Jeroen J. Bax(The Netherlands), Eric Boersma (The Netherlands), Stefan De Hert (The Netherlands),Erik Eeckhout (Switzerland), Gerry Fowkes (UK), Bulent Gorenek (Turkey), Michael G. Hennerici (Germany),Bernard Iung (France), Malte Kelm (Germany), Keld Per Kjeldsen (Denmark), Steen Dalby Kristensen (Denmark),Jose Lopez-Sendon (Spain), Paolo Pelosi (Italy), Francois Philippe (France), Luc Pierard (Belgium),Piotr Ponikowski (Poland), Jean-Paul Schmid (Switzerland), Olav F.M. Sellevold (Norway), Rosa Sicari (Italy),Greet Van den Berghe (Belgium) and Frank Vermassen (Belgium)

92 ESC guidelines

Correspondence to Don Poldermans, Department of Surgery, Erasmus Medical Center, Gravendijkwal 230, 3015 CE Rotterdam, The NetherlandsTel: +31 10 703 4613; fax: +31 10 436 4557; e-mail: d.poldermans@erasmusmc.nl

The content of these European Society of Cardiology (ESC) Guidelines has been published for personal and educational use only. No commercial use is authorized. Nopart of the ESC Guidelines may be translated or reproduced in any form without written permission from the ESC. Permission can be obtained upon submission of awritten request to Oxford University Press, the publisher of the European Heart Journal and the party authorized to handle such permissions on behalf of the ESC.

Disclaimer: The ESC Guidelines represent the views of the ESC and were arrived at after careful consideration of the available evidence at the time they were written. Healthprofessionals are encouraged to take them fully into account when exercising their clinical judgement. The guidelines do not, however, over-ride the individual responsibility ofhealth professionals to make appropriate decisions in the circumstances of the individual patients, in consultation with that patient, and where appropriate and necessary thepatient’s guardian or carer. It is also the health professional’s responsibility to verify the rules and regulations applicable to drugs and devices at the time of prescription.

Additional Contributors: Sanne E. Hoeks (The Netherlands); Ilse Vanhorebeek(Belgium)

ESC Committee for Practice Guidelines (CPG): Alec Vahanian (Chairperson) (France), Angelo Auricchio(Switzerland), Jeroen J. Bax (The Netherlands), Claudio Ceconi (Italy), Veronica Dean (France), GerasimosFilippatos (Greece), Christian Funck-Brentano (France), Richard Hobbs (UK), Peter Kearney (Ireland), TheresaMcDonagh (UK), Keith McGregor (France), Bogdan A. Popescu (Romania), Zeljko Reiner (Croatia), Udo Sechtem(Germany), Per Anton Sirnes (Norway), Michal Tendera (Poland), Panos Vardas (Greece), Petr Widimsky (CzechRepublic)

Document Reviewers: Raffaele De Caterina (CPG Review Coordinator) (Italy), Stefan Agewall (Norway), NawwarAl Attar (France), Felicita Andreotti (Italy), Stefan D. Anker (Germany), Gonzalo Baron-Esquivias (Spain), GuyBerkenboom (Belgium), Laurent Chapoutot (France), Renata Cifkova (Czech Republic), Pompilio Faggiano (Italy),Simon Gibbs (UK), Henrik Steen Hansen (Denmark), Laurence Iserin (France), Carsten W. Israel (Germany), RanKornowski (Israel), Nekane Murga Eizagaechevarria (Spain), Mauro Pepi (Italy), Massimo Piepoli (Italy), HansJoachim Priebe (Germany), Martin Scherer (Germany), Janina Stepinska (Poland), David Taggart (UK), MarcoTubaro (Italy)

European Journal of Anaesthesiology 2010, 27:92–137

Republished with permission from Eur Heart J. 2009; 22:2769–2812

The disclosure forms of all the authors and reviewers are available on the ESC website www.escardio.org/guidelines

Keywords: anaesthesiology, neurological disease, non-cardiac surgery, perioperative cardiac management, post-operative cardiac surveillance,pre-operative cardiac risk assessment, pre-operative cardiac testing, pre-operative coronary artery revascularization, pulmonary disease, renaldisease

+Dosage de l’hémoglobine

n  Déjà fait … pour ceux qui ont considéré que : n  l’ anamnèse hémorragique est positive

n  Est à faire … pour ceux qui envisage une hypotension contrôlée chez cette patiente

n  Souffle = un argument supplémentaire

+Qui a déjà fait …

n  Un test test de grossesse en consultation ?

n  > 5 tests de grossesse en consultation ?

n  > 10 tests de grossesse en consultation ?

+

Trimestre Travail Postpartum

FC VE

1er 2e 3e Latent Actif 2e Imméd. 1 h 2 j. 2 sem.

Mod

ifica

tions

déb

it ca

rdia

que

(% c

ontr

ôle)

Débit cardiaque et grossesse

J.F.-Brichant – ULg – Modifications physiologiques chez la femme enceinte PodCast EIUA Niveau 1

1er bruit élargi (88 %)

Souffle systolique (96 %) Souffle diastolique

(18 %)

B4 (occasionnel) B3 (84 %)

Auscultation cardiaque et grossesse

+Cas clinique

n  La patiente arrive la veille de l’intervention en hospitalisation.

n  Elle est très anxieuse et a très peur de vomir comme une de ses amies en post-opératoire.

+ Question 2 : Allez-vous prescrire une prémédication ? Si oui, laquelle ? Justifiez brièvement

n  A quoi sert une prémédication ? Qu’est-ce qu’une prémédication idéale ? n  Sédation de courte durée

n  Anxiolyse

n  Amélioration de l’hémodynamique peropératoire

n  Hypotension contrôlée

n  Diminution des complications postopératoires

n  NVPO

n  Douleur

+n Peut-on utiliser un moyen non-

pharmacologique ?

n Ce qu’on sait depuis longtemps

n  Egbert LD, Battit GE, Welch CE, Bartlett MK Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor-patient rapport. N Engl J Med. 1964 ;270:825-7

n  Continuous care and empathic anaesthesiologist attitude

in the preoperative period: impact on patient anxietyand satisfactionC. Soltner, J. A. Giquello, C. Monrigal-Martin and L. Beydon*Pole d’Anesthesie Reanimation, Centre Hospitalier Universitaire, Universite d’Angers, Angers, France

* Corresponding author. E-mail: lbeydon.angers@invivo.edu

Editor’s key points

† The preoperative visit andanaesthesia care modelcould affect perioperativeanxiety and patientsatisfaction.

† The effects of anextended preoperativevisit by an empathicanaesthesiologist andcontinuous comparedwith divided care werestudied in day-casepatients.

† Multivariate analysesshowed improved patientsatisfaction and reducedanxiety for empathic andcontinuous anaesthesiacare.

Background. Continuous care (one anaesthesiologist per patient) and anaesthesiologistempathy at the preoperative visit could affect patient anxiety and satisfaction. We testedboth unproven issues in a population at increased risk of anxiety and dissatisfaction.

Methods. In this single-blinded single-centre study, 136 women undergoing gynaecologicday-care surgery were sequentially randomized into four groups: (i) preoperative visit byan anaesthesiologist with either an empathic or a neutral attitude, and (ii) receivingeither continuous or divided care (preoperative visit and anaesthesia performed by twodifferent anaesthesiologists). Preoperative anxiety and wish for information were ratedbefore and after the preoperative visit. Patient appraisal of the anaesthesiologist’sattitude and the quality of care provided was obtained in the operating theatre.

Results. An empathic attitude at the preoperative visit significantly improved the perceptionof both the anaesthesiologist attitude (P,0.001) and the quality of information delivered(P,0.001), compared with a neutral anaesthesiologist attitude. Empathic attitude tendedto decrease patient anxiety. In the operating theatre, patients who had the sameanaesthesiologist (continuous care) exhibited greater satisfaction levels regardinganaesthesiologist behaviour and quality of care (P,0.001). Principal component analysisconfirmed these findings, revealing that an empathic preoperative visit was linked to areduction in preoperative patient anxiety.

Conclusions. The ‘one patient, one anaesthesiologist’ model, in addition to ensuringsufficient time for open discussion and questions at the preoperative visit, improvedpatient satisfaction.

Keywords: clinic visits; information seeking behaviour; organization; surgery, ambulatory

Accepted for publication: 26 January 2011

Preoperative patient information is highly valued by patientsbefore anaesthesia.1 In France, the content of this patientinformation is specified by law2 such that the informationprovided by anaesthesiologists at the preoperative visit isfairly homogeneous. However, it might unduly increasepatient anxiety.3 In order to help decrease situationalanxiety, anaesthesiologists can improve informationexchange, by allowing sufficient time for patient questionsand adapting explanations to patient needs and expec-tations, for example. The true impact of such systematicempathic communication has not been formally assessedwith regard to preoperative patient anxiety.4

The way anaesthesiologists organize their work as a pro-fessional team is another relevant issue. In most cases, thephysician in charge of the anaesthesia is different from theone who performs the preoperative visit. Such a dividedcare model can facilitate work organization and time sche-dules, but is not highly valued by patients.5 6 Practical

issues often oppose these sound recommendations.7 Theeffect of continuous care on patient anxiety has beenassessed by Harms and colleagues8 in the field of anaesthe-sia. However, these authors did not observe a sizeable effect,probably because this was not the main endpoint of theirstudy. We postulated that these two effects could betested jointly in women undergoing day-care gynaecologicsurgery, a patient population known to be especially proneto anxiety.9

MethodsDesign and procedureOver a 6 month period from November 2009 to June 2010,we enrolled unselected patients undergoing day-care gynae-cologic procedure. Patients were invited to participate whilewaiting for the anaesthesiologist visit, under the pretext of

British Journal of Anaesthesia 106 (5): 680–6 (2011)Advance Access publication 16 March 2011 . doi:10.1093/bja/aer034

& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.For Permissions, please email: journals.permissions@oup.com

at Universite catholique de Louvain on January 3, 2013

http://bja.oxfordjournals.org/D

ownloaded from

+n Peut-on utiliser un moyen non-

pharmacologique ?

n Hypnose : n  Kuttner L. Pediatric hypnosis: pre-, peri-, and post-anesthesia.

Paediatr Anaesth. 2012;22:573-7. Review. n  Schnur JB et al. Hypnosis decreases presurgical distress in

excisional breast biopsy patients. Anesth Analg. 2008;106:440-4 n  Saadat H et al. Hypnosis reduces preoperative anxiety in adult

patients. Anesth Analg. 2006;102:1394-6

n  Musique : n  Binns-Turner Pg et al . Perioperative music and its effects on anxiety,

hemodynamics, and pain in women undergoing mastectomy. AANA J. 2011;79:S21-7

n  Li Y, Dong Y. Preoperative music intervention for patients undergoing cesarean delivery. Int J Gynaecol Obstet. 2012;119:81-3.

n  Information : n  Jlala HA et al. Effect of preoperative multimedia information on perioperative

anxiety in patients undergoing procedures under regional anaesthesia. Br J Anaesth. 2010;104:369-74.

n …

+Et si j’utilise un moyen pharmacologique …

+Et pourquoi pas de la clonidine ?

n  Quels effets peut-on attendre de cette prémédication ? n  Sédation et anxiolyse

n  Diminution du saignement per-opératoire

n  Réduction des NVPO

n  Potentialisation des effets analgésiques

n  Dose et moment d’administration pour une chirurgie de l’oreille moyenne avec hypotension contrôlée ? n  300 mcg Per Os 90 minutes avant chirurgie (JM Marchal et al. Clonidine decreases

intraoperative bleeding in middle ear microsurgery Acta Anaesthesiol Scand. 2001;45:627-33)

+ Question 3 : Quel est son risque de NVPO ? Quelle stratégie de prévention semble justifiée chez cette patiente ?

n  Score d’Apfel

Anesthesiology1999; 91:693–700© 1999 American Society of Anesthesiologists, Inc.Lippincott Williams & Wilkins, Inc.

A Simplified Risk Score for Predicting Postoperative

Nausea and Vomiting

Conclusions from Cross-validations between Two CentersChristian C. Apfel, M.D.,* Esa Laara, Ph.D.,† Merja Koivuranta, M.D., Ph.D.,‡ Clemens-A. Greim, M.D.,§Norbert Roewer, M.D.!

Background: Recently, two centers have independently devel-oped a risk score for predicting postoperative nausea and vom-iting (PONV). This study investigated (1) whether risk scores arevalid across centers and (2) whether risk scores based on logis-tic regression coefficients can be simplified without loss ofdiscriminating power.

Methods: Adult patients from two centers (Oulu, Finland: n !520, and Wuerzburg, Germany: n ! 2202) received inhalationalanesthesia (without antiemetic prophylaxis) for various typesof surgery. PONV was defined as nausea or vomiting within 24 hof surgery. Risk scores to estimate the probability of PONV wereobtained by fitting logistic regression models. Simplified riskscores were constructed based on the number of risk factorsthat were found significant in the logistic regression analyses.Original and simplified scores were cross-validated. A com-bined data set was created to estimate a potential center effectand to construct a final risk score. The discriminating power ofeach score was assessed using the area under the receiver op-erating characteristic curves.

Results: Risk scores derived from one center were able topredict PONV from the other center (area under the curve !

0.65–0.75). Simplification did not essentially weaken the dis-criminating power (area under the curve ! 0.63–0.73). No cen-ter effect could be detected in a combined data set (odds ratio !1.06, 95% confidence interval ! 0.71–1.59). The final scoreconsisted of four predictors: female gender, history of motionsickness (MS) or PONV, nonsmoking, and the use of postoper-ative opioids. If none, one, two, three, or four of these riskfactors were present, the incidences of PONV were 10%, 21%,39%, 61% and 79%.

Conclusions: The risk scores derived from one center provedvalid in the other and could be simplified without significantloss of discriminating power. Therefore, it appears that this riskscore has broad applicability in predicting PONV in adult pa-tients undergoing inhalational anesthesia for various types ofsurgery. For patients with at least two out of these four identi-fied predictors a prophylactic antiemetic strategy should beconsidered. (Key words: Logistic regression model; postopera-tive nausea and vomiting; receiver operating characteristiccurve; risk factors; risk score.)

GENERAL anesthesia using volatile anesthetics is associ-ated with an average incidence of postoperative nauseaand vomiting (PONV) ranging between 20% and 30%.1 Ithas been suggested that this may increase patients’ dis-comfort and also increase costs (e.g., antiemetics, read-mission) and unwarranted side effects (e.g., pulmonaryaspiration).2 PONV is thought to be multifactorial, in-volving anesthetic, surgical, and individual risk fac-tors.1–3 A few studies have tried to quantify the relativeimpact of risk factors4–6 and to set up a risk model forthe prediction of PONV.4,7,8 If such a model can beshown to have general applicability, it could provide arational basis to decide who might benefit from prophy-lactic antiemetic therapy.9

An initial step was to construct a risk table for PONVbased on patient-related factors (e.g., gender, history).4

However, because this study was restricted to one typeof anesthesia and surgery, the relative impact was notquantified. This limitation was overcome by a prospec-tive survey in Oulu, Finland, with different types ofanesthesia and surgery, which revealed that the most

* Research Fellow, Department of Anesthesiology, University ofWuerzburg.

† Professor of Statistics, Department of Mathematical Sciences/Sta-tistics, University of Oulu.

‡ Senior Anesthesiologist, Department of Anesthesiology, Universityof Oulu.

§ Senior Anesthesiologist, Department of Anesthesiology, Universityof Wuerzburg.

! Professor of Anesthesiology and Chair, Department of Anesthesiol-ogy, University of Wuerzburg.

Received from the Department of Anesthesiology, University ofWuerzburg, Wuerzburg, Germany; and the Department of Mathemati-cal Sciences/Statistics, University of Oulu, and the Department ofAnesthesiology, Oulu University Hospital, Oulu, Finland. Submitted forpublication November 30, 1998. Accepted for publication May 7,1999. Support was provided solely from institutional and/or depart-mental sources.

Address reprint requests to Dr. Apfel: Department of Anesthesiol-ogy, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuer-zburg, Germany. Address electronic mail to:apfel@anaesthesie.uni-wuerzburg.de

693

Anesthesiology, V 91, No 3, Sep 1999

Anesthesiology1999; 91:693–700© 1999 American Society of Anesthesiologists, Inc.Lippincott Williams & Wilkins, Inc.

A Simplified Risk Score for Predicting Postoperative

Nausea and Vomiting

Conclusions from Cross-validations between Two CentersChristian C. Apfel, M.D.,* Esa Laara, Ph.D.,† Merja Koivuranta, M.D., Ph.D.,‡ Clemens-A. Greim, M.D.,§Norbert Roewer, M.D.!

Background: Recently, two centers have independently devel-oped a risk score for predicting postoperative nausea and vom-iting (PONV). This study investigated (1) whether risk scores arevalid across centers and (2) whether risk scores based on logis-tic regression coefficients can be simplified without loss ofdiscriminating power.

Methods: Adult patients from two centers (Oulu, Finland: n !520, and Wuerzburg, Germany: n ! 2202) received inhalationalanesthesia (without antiemetic prophylaxis) for various typesof surgery. PONV was defined as nausea or vomiting within 24 hof surgery. Risk scores to estimate the probability of PONV wereobtained by fitting logistic regression models. Simplified riskscores were constructed based on the number of risk factorsthat were found significant in the logistic regression analyses.Original and simplified scores were cross-validated. A com-bined data set was created to estimate a potential center effectand to construct a final risk score. The discriminating power ofeach score was assessed using the area under the receiver op-erating characteristic curves.

Results: Risk scores derived from one center were able topredict PONV from the other center (area under the curve !

0.65–0.75). Simplification did not essentially weaken the dis-criminating power (area under the curve ! 0.63–0.73). No cen-ter effect could be detected in a combined data set (odds ratio !1.06, 95% confidence interval ! 0.71–1.59). The final scoreconsisted of four predictors: female gender, history of motionsickness (MS) or PONV, nonsmoking, and the use of postoper-ative opioids. If none, one, two, three, or four of these riskfactors were present, the incidences of PONV were 10%, 21%,39%, 61% and 79%.

Conclusions: The risk scores derived from one center provedvalid in the other and could be simplified without significantloss of discriminating power. Therefore, it appears that this riskscore has broad applicability in predicting PONV in adult pa-tients undergoing inhalational anesthesia for various types ofsurgery. For patients with at least two out of these four identi-fied predictors a prophylactic antiemetic strategy should beconsidered. (Key words: Logistic regression model; postopera-tive nausea and vomiting; receiver operating characteristiccurve; risk factors; risk score.)

GENERAL anesthesia using volatile anesthetics is associ-ated with an average incidence of postoperative nauseaand vomiting (PONV) ranging between 20% and 30%.1 Ithas been suggested that this may increase patients’ dis-comfort and also increase costs (e.g., antiemetics, read-mission) and unwarranted side effects (e.g., pulmonaryaspiration).2 PONV is thought to be multifactorial, in-volving anesthetic, surgical, and individual risk fac-tors.1–3 A few studies have tried to quantify the relativeimpact of risk factors4–6 and to set up a risk model forthe prediction of PONV.4,7,8 If such a model can beshown to have general applicability, it could provide arational basis to decide who might benefit from prophy-lactic antiemetic therapy.9

An initial step was to construct a risk table for PONVbased on patient-related factors (e.g., gender, history).4

However, because this study was restricted to one typeof anesthesia and surgery, the relative impact was notquantified. This limitation was overcome by a prospec-tive survey in Oulu, Finland, with different types ofanesthesia and surgery, which revealed that the most

* Research Fellow, Department of Anesthesiology, University ofWuerzburg.

† Professor of Statistics, Department of Mathematical Sciences/Sta-tistics, University of Oulu.

‡ Senior Anesthesiologist, Department of Anesthesiology, Universityof Oulu.

§ Senior Anesthesiologist, Department of Anesthesiology, Universityof Wuerzburg.

! Professor of Anesthesiology and Chair, Department of Anesthesiol-ogy, University of Wuerzburg.

Received from the Department of Anesthesiology, University ofWuerzburg, Wuerzburg, Germany; and the Department of Mathemati-cal Sciences/Statistics, University of Oulu, and the Department ofAnesthesiology, Oulu University Hospital, Oulu, Finland. Submitted forpublication November 30, 1998. Accepted for publication May 7,1999. Support was provided solely from institutional and/or depart-mental sources.

Address reprint requests to Dr. Apfel: Department of Anesthesiol-ogy, University of Wuerzburg, Josef-Schneider-Str. 2, D-97080 Wuer-zburg, Germany. Address electronic mail to:apfel@anaesthesie.uni-wuerzburg.de

693

Anesthesiology, V 91, No 3, Sep 1999

+Quelle stratégie de prévention chez cette patiente ?

n  Score d’Apfel à 2 (3 : peu d’utilisation d’opioïdes en post-opératoire)

n  Recommandations de la SFAR

+

Ambulatory AnesthesiologySection Editor: Peter S. A. Glass

Society for Ambulatory Anesthesia Guidelines for theManagement of Postoperative Nausea and Vomiting

Tong J. Gan, MD*

Tricia A. Meyer, PharmD, MS†‡

Christian C. Apfel, MD, PhD§

Frances Chung, FRCPC!

Peter J. Davis, MD¶

Ashraf S. Habib, MB, FRCA*

Vallire D. Hooper, MSN, RN,CPAN, FAAN#

Anthony L. Kovac, MD**

Peter Kranke, MD, PhD, MBA††

Paul Myles, MD‡‡

Beverly K. Philip, MD§§

Gregory Samsa, PhD!!

Daniel I. Sessler, MD¶¶

James Temo, CRNA, MSN,MBA##

Martin R. Tramer, MD, DPhil***

Craig Vander Kolk, MD†††

Mehernoor Watcha, MD‡‡‡

The present guidelines were compiled by a multidisciplinary international panel ofindividuals with interest and expertise in postoperative nausea and vomiting(PONV) under the auspices of The Society of Ambulatory Anesthesia. The panelcritically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergo-ing surgery and are at increased risk for PONV. In brief, these guidelines identifyrisk factors for PONV in adults and children; recommend approaches for reducingbaseline risks for PONV; identify the most effective antiemetic monotherapy andcombination therapy regimens for PONV prophylaxis; recommend approaches fortreatment of PONV when it occurs; and provide an algorithm for the managementof individuals at increased risk for PONV.(Anesth Analg 2007;105:1615–28)

Postoperative nausea and vomiting (PONV) is acontinuing concern in surgical patients and the man-agement of this problem is still confusing. In the

United States, more than 71 million inpatient andoutpatient operative procedures are performed eachyear (1). Untreated, PONV occurs in 20%–30% of the

From the *Department of Anesthesiology, Duke UniversityMedical Center, Durham, North Carolina; †Department of Phar-macy, Scott and White Healthcare System, ‡Department of Anes-thesiology, TX A&M University, Temple, Texas; §Department ofAnesthesia and Perioperative Care, UCSF Medical Center at Mt.Zion, San Francisco, California; !Department of Anesthesia, Univer-sity of Toronto, Toronto, Canada; ¶Department of Anesthesiologyand Pediatrics, University of Pittsburgh School of Medicine, Pitts-burgh, Pennsylvania; #School of Nursing, Medical College of Geor-gia, Augusta, Georgia; **Department of Anesthesiology, Universityof Kansas Medical Center, Kansas City, Kansas; ††ConsultantAnesthesiologist, University of Wuerzburg, Wuerzburg, Germany;‡‡Department of Anesthesia and Perioperative Medicine, Alfred Hos-pital, Monash University, Melbourne, Australia; §§Department ofAnesthesiology, Perioperative and Pain Medicine, Brigham and Wom-

en’s Hospital, Harvard Medical School, Boston, Massachusetts; !!De-partment of Biometry and Bioinformatics, Duke University MedicalCenter, Durham, North Carolina; ¶¶Department of OUTCOMES RE-SEARCH, The Cleveland Clinic, Cleveland, Ohio; ##Duke UniversityNurse Anesthetist Program, Durham, North Carolina; ***Divisionof Anesthesiology, Geneva University Hospitals, and Faculty ofMedicine, Geneva, Switzerland; †††Department of Surgery, Di-vision of Plastic Surgery, Johns Hopkins University School ofMedicine, Baltimore, Maryland; and ‡‡‡Department of Anesthe-siology, Texas Children’s Hospital, Houston, Texas.

Accepted for publication September 10, 2007.Supported by an unrestricted educational grant from the Society

for Ambulatory Anesthesia (SAMBA). Baxter (transdermal scopol-amine), GSK (ondansetron), Merck (aprepitant), MGI Pharma

Special Article

Vol. 105, No. 6, December 2007 1615

Ambulatory AnesthesiologySection Editor: Peter S. A. Glass

Society for Ambulatory Anesthesia Guidelines for theManagement of Postoperative Nausea and Vomiting

Tong J. Gan, MD*

Tricia A. Meyer, PharmD, MS†‡

Christian C. Apfel, MD, PhD§

Frances Chung, FRCPC!

Peter J. Davis, MD¶

Ashraf S. Habib, MB, FRCA*

Vallire D. Hooper, MSN, RN,CPAN, FAAN#

Anthony L. Kovac, MD**

Peter Kranke, MD, PhD, MBA††

Paul Myles, MD‡‡

Beverly K. Philip, MD§§

Gregory Samsa, PhD!!

Daniel I. Sessler, MD¶¶

James Temo, CRNA, MSN,MBA##

Martin R. Tramer, MD, DPhil***

Craig Vander Kolk, MD†††

Mehernoor Watcha, MD‡‡‡

The present guidelines were compiled by a multidisciplinary international panel ofindividuals with interest and expertise in postoperative nausea and vomiting(PONV) under the auspices of The Society of Ambulatory Anesthesia. The panelcritically evaluated the current medical literature on PONV to provide an evidence-based reference tool for the management of adults and children who are undergo-ing surgery and are at increased risk for PONV. In brief, these guidelines identifyrisk factors for PONV in adults and children; recommend approaches for reducingbaseline risks for PONV; identify the most effective antiemetic monotherapy andcombination therapy regimens for PONV prophylaxis; recommend approaches fortreatment of PONV when it occurs; and provide an algorithm for the managementof individuals at increased risk for PONV.(Anesth Analg 2007;105:1615–28)

Postoperative nausea and vomiting (PONV) is acontinuing concern in surgical patients and the man-agement of this problem is still confusing. In the

United States, more than 71 million inpatient andoutpatient operative procedures are performed eachyear (1). Untreated, PONV occurs in 20%–30% of the

From the *Department of Anesthesiology, Duke UniversityMedical Center, Durham, North Carolina; †Department of Phar-macy, Scott and White Healthcare System, ‡Department of Anes-thesiology, TX A&M University, Temple, Texas; §Department ofAnesthesia and Perioperative Care, UCSF Medical Center at Mt.Zion, San Francisco, California; !Department of Anesthesia, Univer-sity of Toronto, Toronto, Canada; ¶Department of Anesthesiologyand Pediatrics, University of Pittsburgh School of Medicine, Pitts-burgh, Pennsylvania; #School of Nursing, Medical College of Geor-gia, Augusta, Georgia; **Department of Anesthesiology, Universityof Kansas Medical Center, Kansas City, Kansas; ††ConsultantAnesthesiologist, University of Wuerzburg, Wuerzburg, Germany;‡‡Department of Anesthesia and Perioperative Medicine, Alfred Hos-pital, Monash University, Melbourne, Australia; §§Department ofAnesthesiology, Perioperative and Pain Medicine, Brigham and Wom-

en’s Hospital, Harvard Medical School, Boston, Massachusetts; !!De-partment of Biometry and Bioinformatics, Duke University MedicalCenter, Durham, North Carolina; ¶¶Department of OUTCOMES RE-SEARCH, The Cleveland Clinic, Cleveland, Ohio; ##Duke UniversityNurse Anesthetist Program, Durham, North Carolina; ***Divisionof Anesthesiology, Geneva University Hospitals, and Faculty ofMedicine, Geneva, Switzerland; †††Department of Surgery, Di-vision of Plastic Surgery, Johns Hopkins University School ofMedicine, Baltimore, Maryland; and ‡‡‡Department of Anesthe-siology, Texas Children’s Hospital, Houston, Texas.

Accepted for publication September 10, 2007.Supported by an unrestricted educational grant from the Society

for Ambulatory Anesthesia (SAMBA). Baxter (transdermal scopol-amine), GSK (ondansetron), Merck (aprepitant), MGI Pharma

Special Article

Vol. 105, No. 6, December 2007 1615

prophylaxis, although a systematic review shows thatsome of the data on granisetron may be less reliablethan others (61,68–70,80–83). Tropisetron, 2 mg IV,shows significant efficacy for reducing risk for nausea

and vomiting and is recommended for PONV prophy-laxis (79,84). The 5-HT3 antagonists have a favorableside effect profile and are considered equally safe. Thenumber-needed-to-harm (NNH) with a single dose of

Dexa-methasone

5-HT3antagonist

Non-pharma-cological:Acupuncture

Scopolamine

Ephedrine Dimen-hydrinate

Propofol inPACU

(rescue only)

PromethazineProchlorperazinePerphenazine

Droperidol†or Haloperidol

RegionalAnesthesia

PropofolAnesthesia

Portfolio ofprophylaxisand treatment

Adult Risk Factors Children Risk FactorsPatient Related Environmental Surgery > 30 minHistory of PONV/motion sickness Postop opioids Age > 3 yearsFemale gender Emetogenic surgery Strabismus surgeryNon-smoker (type and duration) History of POV/relative with PONV

Cost-effectiveness

Level of Risk0 RF = 10%1 RF = 10% - 20%2 RF = 30% - 40%3 RF = 50% - 60%4 RF = 70% - 80%

Consider

Patient risk

LowWait and See

High> 2 Interventions/Multimodal Approach

Treatment OptionsIf prophylaxis fails or was not received: use antiemeticfrom different class than prophylactic agentReadminister only if > 6 hours after PACU; do notreadminister dexamethasone or scopolamine

† Use droperidol in children onlyif other therapy has failed andpatient is being admitted tohospitalSome of the drugs may not havebeen studied or approved by theFDA for use in children.

Patient preferencesFear of PONVFrequency ofPONV causingheadaches/migraine

Reducing baseline risksAvoidance/minimization of:Nitrous oxideVolatile anestheticsHigh-dose neostigminePost-op opioids

MediumPick 1 or 2 Interventions for adultsPick > 2 Interventions for children

Figure 3. Algorithm for managementof postoperative nausea and vomiting(PONV).

Table 3. Antiemetic Doses and Timing for Prevention of Postoperative Nausea and Vomiting (PONV) in Adults

Drugs Dose Evidence Timing EvidenceDexamethasone 4–5 mg IV SR (55–57) At induction RCT (57)Dimenhydrinate 1 mg/kg IV SR (58) RCT (59,60)Dolasetron 12.5 mg IV RCT (61) End of surgery; timing

may not affect efficacyRCT (61)

Droperidola 0.625–1.25 mg IV RCT (62,63) End of surgery SR (64)Ephedrine 0.5 mg/kg IM RCT (65,66) End of surgery RCT (65,66)Granisetron 0.35–1.5 mg IV RCT (67–71) End of surgery RCT (68–70)Haloperidol 0.5–2 mg IM/IV SR (72)Prochlorperazine 5–10 mg IM/IV RCT (73) End of surgery RCT (73)Promethazineb 6.25–25 mg IV RCT (74,75) At induction RCT (74,75)Ondansetron 4 mg IV RCT (76) End of surgery SR (67)Scopolamine Transdermal patch SR (77,78) Prior evening or 4 h

before surgeryRCT (78)

Tropisetron 2 mg IV RCT (79) End of surgery Expert opinionNote: These recommendations are evidence-based and not all the drugs have a FDA indication for PONV.Drugs are listed alphabetically.a See Food and Drug Administration (FDA) !black box! warning.b FDA Alert: Should not be used in children less than 2 years old.RCT " randomized, controlled trial; SR " systematic review.

Vol. 105, No. 6, December 2007 © 2007 International Anesthesia Research Society 1619

+Quelle stratégie de prévention chez cette patiente ?

n  Score d’Apfel à 2 (3 : peu d’utilisation d’opioïdes en post-opératoire)

n  Et les autres mesures : réduction anxiété, gestion multimodale de la douleur, hydratation, éviter la décurarisation avec la prostigmine (MLA ?)

+Cas clinique

n  Le jour de l’intervention, le chirurgien insiste pour que vous réduisiez le saignement per-opératoire au maximum.

+ Question 4 : Quelle stratégie proposeriez-vous pour cette patiente afin de réduire le saignement?

n  Ventilation

n  Halogénés à NVPO ?

n  Température du patient

n  Posture

n  Adrénaline locale

n  Hypotension contrôlée n  Nombreuses techniques

n  Magnésium n  Rémifentanil n  …

Controlled hypotension for middle ear surgery: a comparisonbetween remifentanil and magnesium sulphate†

J.-H. Ryu1, I.-S. Sohn2 and S.-H. Do1*

1Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital,166 Kumi-Ro, Bundang-gu, Seongnam-si, Kyonggi-do 463-707, Republic of Korea. 2Department ofAnesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea

*Corresponding author. E-mail: shdo@snu.ac.kr

Background. This prospective, randomized study was designed to compare remifentanil andmagnesium sulphate during middle ear surgery in terms of postoperative pain and other com-plications.

Methods. Eighty patients undergoing middle ear surgery were enrolled in the study. Patientswere randomized into two groups of 40 to receive remifentanil (Group R) or magnesium sul-phate (Group M) infusion. Propofol 2 mg kg21 was administered to induce anaesthesia, whichwas maintained using sevoflurane. Group R received a continuous infusion of remifentaniltitrated between 3 and 4 ng ml21 using target-controlled infusion, whereas Group M receivedan i.v. magnesium sulphate bolus of 50 mg kg21 followed by a 15 mg kg21 h21 continuous infu-sion to maintain a mean arterial pressure (MAP) between 60 and 70 mm Hg. Haemodynamicvariables, surgical conditions, postoperative pain, and adverse effects, such as postoperativenausea and vomiting (PONV) and shivering, were recorded.

Results. Controlled hypotension was well maintained in both groups. MAP and heart ratewere higher in Group R than in Group M after operation. Surgical conditions were not differentbetween the two groups. Postoperative pain scores were significantly lower in Group M thanin Group R (P,0.05). Seventeen patients in Group R (43%) and seven patients in Group M(18%) developed PONV (P!0.01).

Conclusions. Both magnesium sulphate and remifentanil when combined with sevofluraneprovided adequate controlled hypotension and proper surgical conditions for middle earsurgery. However, patients administered magnesium sulphate had a more favourable postopera-tive course with better analgesia and less shivering and PONV.

Br J Anaesth 2009; 103: 490–5

Keywords: anaesthetic techniques, hypotensive; analgesics opioid, remifentanil; ions,magnesium; PONV; surgery, otolaryngological

Accepted for publication: July 10, 2009

Controlled hypotension is required for middle ear surgeryto achieve a bloodless operative field.1 2 Vasodilators(nitroprusside, nicardipine, and nitroglycerine), alpha2A

adrenergic agonists (clonidine and dexmedotomidine), beta-adrenergic antagonists (propranolol and esmolol), alpha-and beta-adrenergic antagonists (labetolol), and high dosesof potent inhaled anaesthetics (halothane, isoflurane, andsevoflurane) have been used to control hypotension duringmiddle ear surgery.1 Remifentanil is also well known toinduce good surgical conditions by controlling hypotensionduring tympanoplasty.2–4 However, intraoperative remifen-tanil infusion can cause postoperative hyperalgesia,5 and

early postoperative analgesia is necessary after remifentanil-based anaesthesia.6

Magnesium sulphate is a non-competitive N-methyl-D-aspartate (NMDA) receptor antagonist with antinociceptiveeffects and also inhibits the entry of calcium ions intocells.7 Magnesium sulphate has been investigated in thecontext of controlling hypotension as a vasodilator,8 9 butno comparative study has been performed on the use ofmagnesium sulphate or remifentanil for controlled hypo-tension during middle ear surgery. We hypothesized that

†This article is accompanied by Editorial I.

# The Author [2009]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

For Permissions, please email: journals.permissions@oxfordjournal.org

British Journal of Anaesthesia 103 (4): 490–5 (2009)

doi:10.1093/bja/aep229 Advance Access publication August 17, 2009

by guest on January 18, 2013http://bja.oxfordjournals.org/

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