26 juin 2017

55 ème STAFF!

Analgésie-ALR-Ambulatoire -

RAAC

Réhabilitation améliorée après hépatectomie par laparotomie

Objectifs :

- optimal pain control through multimodal

analgesia and limiting reliance on opioid-

based medications

- controversy surrounding the use of

epidural analgesia in the ERAS setting,

especially for higher-risk procedures

Preserved Analgesia With Reduction in Opioids Through

the Use of an Acute Pain Protocol in Enhanced Recovery

After Surgery for Open Hepatectomy (In Press)Grant MC, Sommer PM, He C, Li S, Page AJ, Stone AB, Hobson D, Wick E, Wu

CL

Matériels et méthodes : Recueil prospectif de 2013 à 2016 - 180 hépatectomies par

laparotomie - de :

• Analgésie post opératoire et équivalents morphine

• EVA

Pre-ERAS, n = 60 (analgésie traditionnelle)

ERAS, n = 120 (analgésie multimodale, 87 APD)

Résultats :

Pré-ERAS ERAS p

Equivalents morphine

(mg)

H24 116 10 <0,001

H48 85 10 <0,001

H72 60 2,5 <0,001

EVA 5,1 +/- 1,8 4,1 +/-1,6

Apports liquidiens NS

Hypotension NS

Durées de séjour NSERAS sans APD

(n=33)

ERAS avec APD

(n=87)

p

Equivalents morphine

(mg)

H24 65 2,7 <0,001

H48 50 8 <0,001

H72 4,5 1,3 0,56

Conclusions :

A novel ERAS protocol for open

hepatectomy successfully reduced reliance

on perioperative opioids without expensing

adequate analgesia compared with

traditional care. Patients within ERAS

benefitted from application of epidural,

which further reduced opioid requirements

and optimized pain control without

increasing complication rates.

Anesthésie PérimédullaireEn chirurgie digestive

Type de chirurgie Métamères Ponction

de l’espace péridural

Abdominale

sus-mésocolique

T4-T12 T7-T9

Abdominale

sous-mésocolique

T7-T9 T8-T10

Et les rachis « difficiles » ?

APD thoracique: 20 à 50% d’échecs Andersen et coll. Acta Anaesthesiol Scand 2000

Ready LB. Reg Anesth Pain Med 1999

Epidural Versus Paravertebral Nerve Block for

Postoperative Analgesia in Patients Undergoing Open

Liver Resection

A Randomized Clinical Trial

[ Reg Anesth Pain Med 2016;41: 460–

468 ]

47% de coagulopathies en post opératoire après chirurgie hépatique

[ RegAnesthPainMed. 2009;34:308–311 ]

L’espace paravertébral contient les nerfs intercostaux

[ Anesthesiology. 1995;82:1474-1502 ]

Insertion du KT péri et bBPV en pré-op

en T7/T8 ou T8/T9Ropi 0,2%

5 à 8 ml/h

PAM < à J1

Ropi 0,2%

6 à 12 ml/h x 2

Toxicité ø Analgésie multimodale en post-op

Retrait KT à J3 si INR < 2 et Pq >

50.103

Aucune complication liée au KT

Epidural Versus Paravertebral Nerve Block for

Postoperative Analgesia in Patients Undergoing Open

Liver Resection

A Randomized Clinical Trial[ Reg Anesth Pain Med 2016;41: 460–

468 ]

CONCLUSIONS: This study suggests that there is a modest analgesic advantage of thoracic

epidural over bTPVBs for patients after open liver resection

Randomized clinical trial of perioperative nerve block

and continuous local anaesthetic infiltration via wound

catheter versus epidural analgesia in open liver

resection (LIVER 2 trial)[ BJS 2015; 102: 1619–1628 ]

Conclusion: Wound infltration is associated with a reduced time to recovery after

open liver resection compared with epidural analgesia. TEA does not offer an

advantage over CWI in terms of attenuation of the infammatory response or pain

scores.

Conclusion

Soldat Arme Fatale ?

?