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Anaesth Crit Care Pain Med (2023) 101264
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Anaesthesia Critical Care & Pain Medicine

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Guidelines
Guidelines on perioperative optimization protocol for the adult patient

2023§
Sébastien Bloc a,b,*, Pascal Alfonsi c, Anissa Belbachir d, Marc Beaussier e, Lionel Bouvet f,
Sébastien Campard g, Sébastien Campion h,i, Laure Cazenave j,k, Pierre Diemunsch l,
Sophie Di Maria m, Guillaume Dufour n, Stéphanie Fabri o, Dominique Fletcher p,
Marc Garnier q, Anne Godier r, Philippe Grillo s, Olivier Huet t, Alexandre Joosten u,v,
Sigismond Lasocki w, Morgan Le Guen x, Frédéric Le Saché b,y, Isabelle Macquer z,
Constance Marquis A, Jacques de Montblanc B, Axel Maurice-Szamburski s,
Yên-Lan Nguyen C, Laura Ruscio B,D, Laurent Zieleskiewicz E, Anaı̂s Caillard F,
Emmanuel Weiss G,H,I
a
Clinical Research Department, Ambroise Pare Hospital Group, Neuilly-sur-Seine, France
b
Department of Anesthesiology, Clinique Drouot Sport, Paris, France
c
Department of Anesthesia, University of Paris Descartes, Groupe Hospitalier Paris Saint-Joseph, 185 rue Raymond Losserand, F-75674 Paris Cedex 14, France
d
Service d’Anesthésie Réanimation, UF Douleur, Assistance Publique Hôpitaux de Paris, APHP.Centre, Site Cochin, Paris, France
e
Department of Digestive, Oncologic and Metabolic Surgery, Institut Mutualiste Montsouris, Université de Paris, 42 Boulevard Jourdan, 75014, Paris, France
f
Department of Anaesthesia and Intensive Care, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
g
Clinique Jules-Verne, 44300 Nantes, France
h
AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département d’Anesthésie-Réanimation, F-75013 Paris, France
i
Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
j
Department of Anaesthesia and Critical Care, Hospices Civils de Lyon, Lyon, France
k
Groupe Jeunes, French Society of Anaesthesia and Intensive Care Medicine (SFAR), 75016 Paris, France
l
Unité de Réanimation Chirurgicale, Service d’Anesthésie-réanimation Chirurgicale, Pôle Anesthésie-Réanimations Chirurgicales, Samu-Smur, Hôpital de
Hautepierre, Hôpitaux Universitaires de Strasbourg, 1, Avenue Molière, 67098 Strasbourg Cedex, France
m
Department of Anaesthesiology and Critical Care, AP-HP, Hôpital Pitié-Salpêtrière, Paris, France
n
Service d’Anesthésie-Réanimation, CHU de Pitié-Salpêtrière, 47-83, Boulevard de l’Hôpital, 75013 Paris, France
o
Faculty of Economics, Management & Accountancy, University of Malta, Malta
p
Université de Versailles-Saint-Quentin-en-Yvelines, Assistance Publique-Hôpitaux de Paris, Hôpital Ambroise-Paré, Service d’Anesthésie, 9, Avenue Charles-
de-Gaulle, 92100 Boulogne-Billancourt, France
q
Sorbonne Université, GRC 29, DMU DREAM, Service d’Anesthésie-Réanimation et Médecine Périopératoire Rive Droite, Paris, France
r
Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, France
s
Clinique Juge, Marseille, France
t
CHU de Brest, Anesthesia and Intensive Care Unit, Brest, France
u
Department of Anesthesiology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
v
Department of Anesthesiology and Intensive Care, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Université Paris-Saclay, Paul Brousse Hospital,
Assistance Publique Hôpitaux de Paris (APHP), Villejuif, France
w
CHU d’Angers, Anesthesia and Intensive Care Unit, Angers, France
x
Paris Saclay University, Department of Anaesthesia and Pain Medicine, Foch Hospital, 92150 Suresnes, France
y
DMU DREAM Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France
z
Bordeaux University Hospitals, Bordeaux, Anaesthesia and Intensive Care Medicine Department, Bordeaux, France
A
Clinique du Sport, Département d’Anesthésie et Réanimation, Médipole Garonne, 45 rue de Gironis - CS 13 624, 31036 Toulouse Cedex 1, France
B
Departments of Anesthesiology and Intensive Care Paris-Saclay University, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
C
Anesthesiology and Critical Care Medicine Department, Cochin Academic Hospital, APHP, Université de Paris, 75014 Paris, France
D
INSERM U 1195, Université Paris-Saclay, Saint-Aubin, Iˆle-de-France, France
E
Service d’Anesthésie Réanimation, Hôpital Nord, AP-HM, Marseille, Aix Marseille Université, C2VN, France
F
Centre Hospitalier Universitaire La Cavale Blanche Université de Bretagne Ouest, Anaesthesiology, Critical Care and Perioperative Medicine Department,
Brest, France
G
Department of Anaesthesiology and Critical Care, Beaujon Hospital, DMU Parabol, AP-HP, Nord, Clichy, France
H
University of Paris, Paris, France
I
Inserm UMR_S1149, Centre for Research on Inflammation, Paris, France
§
Text validated by the Comité des Référentiels Cliniques (clinical guidelines committee) of the SFAR on 13/06/2022 and the Conseil d’Administration (board of directors) of
the SFAR on 29/06/2022.
* Corresponding author at: Clinical Research Department, Ambroise Pare Hospital Group, Neuilly-sur-Seine, France.
E-mail address: [email protected] (S. Bloc).
https://doi.org/10.1016/j.accpm.2023.101264
2352-5568/ C 2023 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.
S. Bloc, P. Alfonsi, A. Belbachir et al. Anaesth Crit Care Pain Med (2023) 101264
A R T I C L E I N F O A B S T R A C T
Article history: Objective: The French Society of Anesthesiology and Intensive Care Medicine [Société Française
Available online xxx d’Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of
perioperative optimization programs.
Keywords: Design: A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest
Expert guidelines policy was developed at the outset of the process and enforced throughout. The entire guidelines process
Perioperative optimization program was conducted independently of any industry funding. The authors were advised to follow the principles
Enhanced recovery after surgery
of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide
assessment of quality of evidence.
Methods: Four fields were defined: 1) Generalities on perioperative optimization programs; 2)
Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the
objective of the recommendations was to answer a number of questions formulated according to the
PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive
bibliographic search was carried out using predefined keywords according to PRISMA guidelines and
analyzed using the GRADE1 methodology. The recommendations were formulated according to the
GRADE1 methodology and then voted on by all the experts according to the GRADE grid method. As the
GRADE1 methodology could have been fully applied for the vast majority of questions, the
recommendations were formulated using a ‘‘formalized expert recommendations’’ format.
Results: The experts’ work on synthesis and application of the GRADE1 method resulted in
30 recommendations. Among the formalized recommendations, 19 were found to have a high level
of evidence (GRADE 1) and ten a low level of evidence (GRADE 2). For one recommendation, the GRADE
methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any
response in the literature. After two rounds of rating and several amendments, strong agreement was
reached for all the recommendations.
Conclusions: Strong agreement among the experts was obtained to provide 30 recommendations for the
elaboration and/or implementation of perioperative optimization programs in the highest number of
surgical fields.
C 2023 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All
rights reserved.
Organizing society: Société Française d’Anesthésie et de Introduction

Réanimation (SFAR).
Expert coordinator: Sébastien Bloc Enhanced recovery after surgery (ERAS) is a form of evidence-
Organizers from the Comité des Référentiels Cliniques of the based, standardized, multidisciplinary management. The concept
SFAR: Emmanuel Weiss and Anaı̈s Caillard. was first introduced in the 1990s by Henrik Kehlet under the name
Expert group (in alphabetical order): P. Alfonsi, A. Belbachir, of fast-track surgery [1,2]. Initially developed in digestive and then
M. Beaussier, L. Bouvet, S. Campard, S. Campion, P. Diesmunch, S. Di in orthopaedic surgery, ERAS is now applied in numerous surgical
Maria, G. Dufour, S. Fabri, D. Fletcher, A. Godier, P. Grillo, O. Huet, A. specialities.
Joosten, S. Lasocki, M. Le Guen, F. Le Sache, I. Macquer, C. Marquis, J. Over recent years, in collaboration with other learned societies,
de Montblanc, A. Maurice-Szamburski, Y-L. NGuyen, L. Ruscio, L. the French Society of Anaesthesia and Intensive Care has issued
Zieleskiewicz. numerous ERAS guidelines in specific surgical fields: colorectal
Literature search and referencing: Laure Cazenave and Marc surgery (2014) [3], orthopaedic surgery (2019) [4], pulmonary
Garnier. lobectomy (2019) [5] and cardiac surgery (2021) [6]. These
Reading groups: different recommendations emphasize the common points in most
SFAR clinical reference committee: Marc Garnier (President), operations of the many ERAS principles to be applied throughout a
Alice Blet (Secretary), Anais Caillard, Hélène Charbonneau, Isabelle patient’s pathway. It seemed interesting to put forward a global
Constant, Hugues de Courson, Philippe Cuvillon, Marc-Olivier approach toward these converging elements, the objective being to
Fischer, Denis Frasca, Matthieu Jabaudon, Audrey De Jong, Daphné establish a series of foundational guidelines, whatever the
Michelet, Stéphanie Ruiz, Emmanuel Weiss. operations performed (specialities or surgical specificities).
SFAR board of directors: Pierre Albaladéjo (President); Jean- The goal of these formalized expert recommendations (FER) is
Michel Constantin (1st vice president); Marc Léone (2nd vice to propose a tool conducive to the elaboration and/or implemen-
president); Karine Nouette-Gaulain (general secretary); Frédéric tation of optimized perioperative programs in a maximum number
Le Saché (associate general secretary); Marie-Laure Cittanova of surgical fields. While the techniques and specificities of a given
(treasurer); Isabelle Constantin (associate treasurer); Julien surgical intervention are not the objects of these recommenda-
Amour; Hélène Beloeil; Valérie Billard; Marie-Pierre Bonnet; tions, the different fields may subsequently be linked up with their
Julien Cabaton; Marion Costecalde; Laurent Delaunay; Delphine specific toolkits to the aforementioned foundational guidelines.
Garrigue; Pierre Kalfon; Olivier Joannes-Boyau ; Frédéric Lacroix; Wishing to propose a broadly applicable common foundation,
Olivier Langeron; Sigismond Lasocki; Jane Muret ; Olivier Rontes; the experts determined that a measure valid in at least three areas
Nadia Smail ; Paul Zetlaoui. (surgical specialities and/or specificities) could be the subject of a
2
recommendation in the present FER. As regards each measure, the The recommendation fields
objective is not to establish an exhaustive inventory of the fields in
which it has been assessed, but rather to evaluate its positive (or The recommendations formulated involved the following four
non-positive) impact on the perioperative pathway. So it is that in fields:
the different argumentations, not every field was systematically Field 1: Generalities on perioperative optimization program
discussed, and some of the recommendations may not be Questions:
applicable to certain specific surgical interventions.
The term we have used (‘‘perioperative optimization program’’) Does the implementation of a perioperative optimization
takes into account not only the notion of ERAS but also the patient’s program have an impact on the length of hospital stay or the
pre-, per- and postoperative pathway. occurrence of postoperative complications?
As in the preceding FER on this theme, the expert group decided Does there exist a place for community-based practice in a
to consider the length of hospital stay and postoperative perioperative optimization program?
complications as primary endpoints for evaluation of the effects Does the participation of a dedicated multi-professional team
of a measure included in a ‘‘perioperative optimization program’’. have an impact on the length of hospital stay or the occurrence
The postoperative complications taken into consideration were of complications?
general (infectious, thromboembolic, cardiovascular, neuro-cogni- Should all patients be included in a perioperative optimization
tive, pulmonary, acute pain. . .) and surgical (anastomotic leakage, program?
impaired wound healing, haemorrhage).
Field 2: Preoperative measures
Methods Questions:
General organization Does a pre-habilitation program prior to surgery have an impact

on the occurrence of postoperative complications or length of
These guidelines are the result of the work of a committee hospital stay?
consisting of experts convened by the SFAR. Prior to the onset of Do the conditions of preoperative fasting have an impact on the
analysis, each expert filled out a declaration concerning possible length of hospital stay or the occurrence of complications?
competing interests. The agenda for the group was predetermined. At Does sedative premedication have an impact on the occurrence
first and in conjunction with the coordinators, the organizing of postoperative complications or length of hospital stay?
committee defined the questions. The committee then designated the Does hospital admission on the day of surgery have an impact on
experts who would be in charge of each question. After an initial the length of hospital stay or the occurrence of complications?
meeting of the expert group, the questions were formulated in Do different preoperative blood-sparing strategies have an
accordance with the PICO format (Patient, Intervention, Comparison, impact on the length of hospital stay or the occurrence of
Outcome). Analysis of the literature and formulation of the complications?
recommendations was then carried out in accordance with the
GRADE methodology (Grade of Recommendation Assessment, Devel- Field 3: Intraoperative measures
opment and Evaluation). A level of evidence for each of the cited Questions:
bibliographic references was determined according to the type of
study and could be reevaluated by taking into account the Does the choice of anaesthetic agents have an impact on the
methodological quality of the study. An overall level of evidence occurrence of postoperative complications or length of hospital
was determined for each endpoint based on the levels of evidence of stay?
each bibliographic reference, the consistency of the results between Do the modalities of ventilation have an impact on the
the different studies, the direct or indirect nature of the evidence, and occurrence of postoperative complications or length of hospital
analysis of the cost and the extent of benefit. An overall ‘‘high’’ level of stay?
evidence justified formulation of a ‘‘strong’’ recommendation (it is Does the administration of local anaesthetics by perineural,
recommended to do/it is not recommended to do. . . GRADE 1+/1 ). neuro-axial, systemic or local route have an impact on the
An overall moderate or low level of evidence led to the formulation of occurrence of postoperative complications or length of hospital
an ‘‘optional’’ recommendation (it is probably recommended to do/it stay?
is probably not recommended to do. . . GRADE 2+/2 ). When the level Does perioperative optimization of fluid intake and blood
of evidence was very low or the literature practically non-existent, pressure have an impact on the length of stay and postoperative
the question could be the subject of a recommendation in the form of complications?
expert opinion (the experts suggest. . .). The proposals for recom- Does the monitoring of the depth of anaesthesia and analgesia
mendations were presented to all the experts and discussed one by have an impact on the length of hospital stay and the occurrence
one. The goal was not necessarily to arrive at a single and convergent of complications?
opinion on all the proposals, but rather to distinguish points of Does prevention of perioperative hypothermia have an impact
agreement from points of disagreement or indecision. Each on the length of hospital stay and occurrence of complications?
recommendation was independently assessed by each expert and Does the application of a protocol for the specific prevention of
individually rated on a scale ranging from 1 (complete disagreement) nausea and vomiting have an impact on the length of hospital
to 9 (complete agreement). The general or overall rating was stay?
determined according to the GRADE grid methodology. In order to Does perioperative administration of dexamethasone have an
validate a recommendation on the basis of a given criterion, at least impact on the length of hospital stay or the occurrence of
50% of the experts had to express a generally convergent opinion, postoperative complications?
while fewer than 20% expressed a divergent opinion. To issue a strong Does perioperative administration of tranexamic acid have an
recommendation, at least 70% of the participants had to have a impact on length of hospital stay or occurrence of complica-
generally convergent opinion. In the absence of strong agreement, the tions?
recommendations were reformulated and once again rated, the Does antibiotic prophylaxis have an impact on the length of
objective still being to arrive at a consensus. hospital stay or the occurrence of complications?
3
Does the monitoring of curarization have an impact on the parallel, reduced postoperative complications and lengths of
length of hospital stay or the occurrence of complications? hospital stay were observed in patients having benefited from
strong adherence to the protocol.
Field 4: Postoperative measures Benefit in terms of average length of stay (LOS) was found in
Questions: most of the randomized studies and meta-analyses, without
increased readmission rate, whatever the type of surgery
Does a postoperative analgesia technique have an impact on the [9,10]. Reduced LOS without increased readmission was particu-
length of hospital stay or the occurrence of complications? larly pronounced in major programmed digestive surgery
Does thromboprophylaxis have an impact on the length of (colorectal surgery, bariatric surgery, hepatic and pancreatic
hospital stay or the occurrence of complications? surgery, oesophagal surgery) [11–19] and in emergency surgery
Does the implementation of postoperative optimization mea- [20]. In cardiothoracic surgery, a reduced overall length of stay
sures in post-anaesthesia care units have an impact on the was associated with reduced lengths of stay in critical care units
length of hospital stay or the occurrence of complications? and in postoperative ventilation units [21–23]. In programmed
Does early postoperative oral feeding have an impact on the orthopaedic surgery, the application of ERAS principles was
length of hospital stay or the occurrence of complications? found to reduce LOS and, in emergency surgery, to reduce the
Does early ambulation have an impact on the length of hospital time elapsed prior to intervention [24–26]. In carcinologic ENT
stay or the occurrence of complications? surgery with flap reconstruction, the objectives of the North
Does utilization of a list of criteria for hospital discharge have an American ERAS program guideline are to reduce morbidity,
impact on the length of hospital stay or the occurrence of postoperative complications and length of hospital stay [27]. In
complications? carcinologic urological and gynecological surgery, meta-analyses
once again showed reduced LOS when an ERAS program was
applied [28,29].
Synthesis of the results As regards the benefits in terms of reduced postoperative
complications, notwithstanding the heterogeneous definitions of
Expert synthesis and application of the GRADE method led to postoperative complications and measures to be included in
the formulation of 30 recommendations, among which 19 pre- rehabilitation protocols, the results of the relevant studies and
sented a high level of evidence (GRADE 1), while 10 showed a meta-analyses have been positive. The rare studies having
moderate level of evidence. As regards the remaining recommenda- assessed the impact of ERAS programs on postoperative pain have
tion, the GRADE method could not be applied, and an expert opinion likewise reported positive results [30,31].
was issued in its place. After two rounds of rating and an amendment, Question: Does there exist a place for community-based
strong agreement was achieved for all the recommendations. For two medicine during the preoperative and postoperative phases of a
questions, no recommendation could be formulated. perioperative optimization program?
The SFAR urges all anaesthetists and intensivists to apply these Experts: Constance Marquis (Toulouse), Guillaume Dufour (Paris),
FER, the objective being to ensure top-quality care. However, in the Sébastien Bloc (Paris)
application of these recommendations, each expert is called upon
to exercise his own judgment, taking into account his own field of ABSENCE OF RECOMMENDATION – In the present-day state of
expertise, so as to decide on the means of intervention best suited knowledge, the experts are not in a position to issue a
to the state of the patient of whom he is in charge. recommendation on the role of community-based medicine during
Lastly, a schema summarizing the main steps of the periopera- the preoperative and postoperative phases of a perioperative
tive optimization program proposed in these recommendations is optimization program.
provided in Appendix 1 (Supplemantary material).
FIELD 1: Generalities on perioperative optimization program
Coordinator: Sébastien Bloc (Paris) Question: Does the participation of a dedicated multi-
Question: Does implementation of a perioperative optimi- professional team have an impact on the length of hospital stay
zation program have an impact on the length of hospital stay or and the occurrence of complications?
the occurrence of postoperative complications? Experts: Constance Marquis (Toulouse), Guillaume Dufour (Paris),
Experts: Constance Marquis (Toulouse), Guillaume Dufour (Paris), Sébastien Bloc (Paris)
Sébastien Bloc (Paris)
R1.2 – The experts suggest that the implementation and
R1.1 – It is recommended to set up and apply a perioperative monitoring of perioperative optimization programs be carried
optimization program in order to reduce the length of hospital stay out by a multi-professional team, with time dedicated to the
and the incidence of postoperative complications. patient pathway.
GRADE 1+ (STRONG AGREEMENT) EXPERT OPINION (STRONG AGREEMENT)
Argumentation:
Perioperative optimization programs are multimodal and Argumentation:
multidisciplinary programs helping to optimize patient manage- Present-day literature on the subject is very scarce. Most of the
ment. Optimization is aimed at reducing the length of hospital stay, published articles consist of experience feedback, expert view-
without increasing – and possibly decreasing – readmissions and points or descriptive studies on the role of coordinators or other
complications. staff members involved in optimized management of patient
The introduction of a perioperative optimization program pathways [32–37]. These studies highlight the importance of
contributes to enhanced compliance with management principles. effective collaboration and communication in a multidisciplinary
In two prospective multicentre studies on colorectal and ortho- team. Time dedicated to pathway coordination should be
paedic surgery, improved adherence to the different steps and to envisioned.
the different principles of ERAS was found in the establishments Question: Should all patients be included in a perioperative
having set up a perioperative optimization program [7,8]. In optimization program?
4
Experts: Constance Marquis (Toulouse), Guillaume Dufour (Paris), and for each type of surgery, and the proven benefits will vary
Sébastien Bloc (Paris) according to the type of operation:
R1.3 – It is recommended to include all patients in a perioperative - major abdominal surgery: reduced length of stay, reduced
optimization program, particularly elderly, fragile or comorbid postoperative (pulmonary) complications and morbidity
patients, for whom this type of management helps to reduce rates [58,61–64];
of postoperative complication and duration of hospital stay. - thoracic and cardio-vascular surgery: reduced postoperative
complications, improved functional capacities and length of
GRADE 1+ (STRONG AGREEMENT)
hospital stay [65,66];
Argumentation: - gynecological and urologic oncology surgery: improved quality
The different French recommendations suggest that all patients of life [67–70];
should be included in a perioperative optimization program [3– - prosthetic (hip or knee) orthopaedic surgery (PTH, PTG) and
6]. While questions on the benefits and safety of this type of spine surgery: scientific data still insufficient to measure the
program in elderly (>65 years) and/or fragile patients have been effect of prehabilitation [71–73].
voiced, studies have shown its benefits in terms of recovery,
incidence of (minor or major) complications and length of stay, For fragile patients undergoing an operation, prehabilitation
including in this population. While digestive surgery has been the may be associated with reduced mortality, but evidence remains
most widely studied [38,39], similarly positive results have been limited [74].
reported in other specialities [40–44], including emergency Question: Do preoperative fasting conditions have an impact
surgery [26,45]. As regards patient safety, there has been no on length of hospital stay or occurrence of complications?
documented increase in readmission rates for elderly or fragile Experts: Lionel Bouvet (Lyon), Sébastien Bloc (Paris)
patients included in an ERAS program [46].
Moreover, no difference in adherence to protocols has been R2.2 – For solids, it is recommended to limit the duration of
observed according to age, a factor highlighting the feasibility of preoperative fasting to six hours and to encourage intake of clear
these protocols in elderly and/or fragile patients [47,48]. That said, fluids (water, tea or coffee with or without sugar, fruit juice
the authors of these studies emphasized on the importance of a without pulp up until two hours before the operation, the
medical education protocol tailored to this population [49–52]. objectives being to reduce preoperative anxiety and length of
To conclude, it is recommended to systematically include highly hospital stay.
fragile patients in a multidisciplinary optimized program so as to
improve their clinical evolution, taking into account the fact that the
goals and the modalities shall need to be personalized and adapted so Argumentation:
that ERAS can become the reference in the management of these The recent recommendations of the learned societies on
patients. The anaesthesia-intensive care teams shall have a key role to preoperative fasting validate the safety of fluid intake up until
assume in the implementation of these programs. This recommen- two hours prior to programmed surgery, in patients without major
dation is in line with an identical recommendation recently issued by issues of gastric emptying [3,75,76]. There exists no proof that fluid
the Italian society of anaesthesia and intensive care [49]. intake up until two hours prior to anaesthesia increases the risk of
FIELD 2: Preoperative measures pulmonary inhalation or gastric fluid regurgitation.
Coordinator: Axel Maurice-Szamburski (SFAR) According to the recommendations of the ESPEN (European
Question: Does a prehabilitation program prior to surgery Society for Clinical Nutrition and Metabolism), sweet beverages
have an impact on the length of hospital stay or the occurrence should be administered up until two hours before surgery so as to
of postoperative complications? reduce discomfort and preoperative anxiety. Ingestion of these
Expert: Stéphane Fabri (Montpellier) liquids may also be considered, in comparison with prolonged
fasting, as means of shortening hospital stay and insulin resistance
R2.1 – It is probably recommended to implement a prehabilitation [76]. The more major the surgery and the longer the planned
program prior to surgery so as to reduce morbidity and postoperative stay, the stronger the effect of preoperative
postoperative length of hospital stay. ingestion of sweet beverages, which is not associated with
increased or decreased postoperative complications.
Question: Does sedative premedication have an impact on
Argumentation: the length of hospital stay or the occurrence of postoperative
Today, prehabilitation is frequently proposed prior to a major complications?
surgical intervention. A 2021 meta-analysis covering 178 observa- Expert: Axel Maurice-Szamburski (Marseille)
tional studies demonstrated the benefits of pre-habilitation in
terms of reduced morbidity, length of hospital stay and (in some R2.3 – It is not recommended to systematically prescribe sedative
cases) postoperative complications [53]. However, the measures premedication before an intervention in view of reducing the
included in the programs studied and the types of operations taken occurrence of postoperative complications.
into consideration are markedly heterogeneous [54–57]. Frequent-
GRADE 1- (STRONG AGREEMENT)
ly multimodal approaches are based mainly on information,
education, physical exercise (at times supervised by a healthcare Argumentation:
professional), smoking cessation, nutritional care and psychologi- For patients, the perioperative period is recognized as
cal support [56,58]. In all of the studies, the implementation of a anxiogenic. However, in a large-scale randomized prospective
prehabilitation program occurred at least seven days before the study, benzodiazepine premedication did not present benefit in
operation [56,58,59,60]. All in all, multimodal prehabilitation is terms of patient experience after general anaesthesia (satisfaction
likely to have a better impact on functional outcomes than any of patients in the lorazepam group: 72% (95%CI [67–70]; n = 330)
single measure. The benefits of prehabilitation combined with vs. 73% ([68–71]; n = 319) in the ‘‘non- premedication’’ group and
physical rehabilitation are greater than with prehabilitation vs. 71% ([67–70]; n = 322) in the ‘‘placebo’’ group – p = 0.38)
alone. The programs should be personalized for each patient [77]. Results were similar in the sub-group of patients most
5
anxious before surgery. No benefit was found in terms of the Argumentation:

patient’s conditioning to his arrival in the operating theater; the Admission on the day of the operation (‘‘D0’’) is commonly
ineffectiveness of benzodiazepine premedication with regard to carried out in the ambulatory surgery pathway, whatever the
patient anxiolysis prior to anaesthesia was thereby confirmed. technical level of the operation. For conventional hospitalization
On the other hand, premedication with lorazepam was surgery involving patients with severe comorbidities and whose
associated with prolonged extubation times (17 min CI95% [14– perioperative pathway presents a risk of complications, admission
20] in the lorazepam group vs. 12 min [11–13] in the non- on the day of an operation is not current practice in France. There
premedication group, and vs. 13 min [12–14] in the placebo group – exist few studies on the subject and as they are essentially based on
p < 0.001) [77]. The authors also observed the absence of early observational studies, their methodological quality is generally
cognitive recovery in the recovery room in the premedicated group poor. However, the data published on D0 admission highlight an
(51% [45–56] in the lorazepam group vs. 71% [63–73] in the non- overall reduction in the average length of stay (LOS). The LOS
premedicated group and vs. 64% [59,60,61–66] in the placebo group reduction often goes beyond the single preoperative night insofar
– p < 0.001). Notwithstanding heterogeneous findings (I2 = 63%), a as the organization of D0 admission is often associated with other
recent meta-analysis including 12 studies and 1445 patients measures permitting reduced postoperative length of stay. In
corroborated these results, highlighting prolonged recovery time Ireland, in a cohort of patients having undergone surgery for rectal
after sedative premedication [78]. In the same meta-analysis, cancer, Stephens et al. reported a reduction from 16 to 12 nights of
benzodiazepine premedication was found to be beneficial with stay duration that coincided with an increase from 15.9 to 98.5% of
regard to nausea (OR 0.34, CI95% [0.21–0.55] – p < 0.001), but not patient admissions on D0, leading to an increase in the number of
vomiting (p = 0.08), or postoperative dizziness (p = 0.68). In this patients treated by year [90]. In cardiac surgery, Patel et al. showed
meta-analysis, possible benefits of benzodiazepine premedication that in the United States, using a national register, D0 (n = 467) vs.
with regard to patient anxiety were not identified (p = 0.24) [78]. D-1 (n = 371) admission was associated with reduced length of
A recent study indicated the effects of benzodiazepine hospital stay: (5.9d 0.25d vs. 7.2d 0.3d respectively – p <
premedication as resulting from the choices of general anaesthesia 0.001), without any difference in intra-hospital mortality or
modalities [79]. While midazolam administered as premedication postoperative complications [91]. What is more, the medico-
did not reduce postoperative nausea in the group of patients economic evaluation highlighted a decrease in costs of stay
having received propofol anaesthesia, the authors observed benefit ($51126 $1184 for D0 admission vs. $57703 $1508 for admission
in the group of patients having received sevoflurane anaesthesia D-1). Cost saving amounting to 30000 dollars was found in
(p < 0.001). Midazolam was also significantly associated with neurosurgery by Pepper et al. for 87 patients admitted on D0
delayed eye opening in the propofol group (p < 0.001), but not in compared to 112 admitted the day before, without any modification
the sevoflurane group [79]. in the rate of cancelled interventions [92].
If sedative premedication by benzodiazepine seemed associated Concerning complications, a study on 234 surgical site
with a prolonged stay in the post-interventional surveillance room, this infections in a cohort of 4596 patients in orthopaedic surgery
was probably due to the adverse effects ascribable to this pharmaco- showed no difference in incidence according to modality of
logical class, such as an increased incidence of oxygen desaturation, admission (OR admission D-1: 1.38 [0.99–1.93] – p = 0.06) [93].
particularly in the elderly population [80]. That said, a systematic One of the fears concerning D0 admission involves a possible
Cochrane review of 17 studies showed no link between sedative increase in cancellation rates compared to admission the day
premedication and the overall duration of hospitalization [81]. before, during which a certain number of missing complementary
Often prescribed to reduce postoperative pain or prevent it tests can still be carried out so as to assess surgical risk. In the
from becoming chronic, gabapentinoids have a marked sedative literature, however, cancellation seems to be connected not with
effect that has led some authors to propose them as means of admission modalities, but rather with models of organization of
sedative premedication [82]. However, the sedative effects are the preoperative pathway [92]. In fact, the organization can be
negatively associated with dizziness and visual disorders in the carried out according to the same modalities as in outpatient
framework of an enhanced recovery protocol [83,84]. Moreover, surgery, essentially relying on coordination teams (cf. R1.3).
their possible alleviation of postoperative pain has been called into Insurance coverage conditions and inpatient bed availability often
question [85–87] and recently updated expert recommendations occasion cancellation, as do medical contraindications or insuffi-
in management of postoperative pain call for avoidance of their cient assessment, and they represent 10 to 80% of cases [94–
systematic utilization [88]. 100]. Differences in incidence can be partially explained by
While melatonin possesses an anxiolytic effect comparable in heterogeneity in preoperative evaluation practices. In some
premedication settings to that of benzodiazepines, there are counties, the pre-admission anaesthesia consultation is optional,
currently not enough data in the literature concerning its tolerance even though some authors have highlighted its importance, if only
to suggest a favorable benefit/risk ratio [89]. as a means of limiting the number of cancellations for medical
To conclude, given the absence of patient benefit and the reasons [98,101]. In France, mandatory anaesthesia consultation
existence of deleterious effects on postoperative recovery, it is should facilitate D0 admission by avoiding insufficient evaluation.
recommended to refrain from systematically administering seda- Question: Do different preoperative blood-sparing strategies
tive premedication prior to an intervention carried out in the have an impact on the length of stay and the occurrence of
framework of an enhanced recovery protocol. complications?
Question: Does admission to hospital on the day of surgery Expert: Sigismond Lasocki (Angers)
have an impact on the length of stay or the occurrence of
complications? R2.5 – It is probably recommended to implement a patient blood
Expert: Fréderic Le Sache (Paris) management program in order to reduce the length of stay and the
occurrence of postoperative complications.
R2.4 – It is probably recommended to admit patients on the day of GRADE 2+ (STRONG AGREEMENT)
their operation so as to reduce the length of hospital stay without
modifying the occurrence of complications. Argumentation:
Patient blood management programs (PBM) have led to
GRADE 2+ (Accord fort)
international guidelines for management of scheduled surgery
6
patients [102], and represent a present-day priority for the WHO study on a large-scale cohort (around 150,000 patients) likewise
[103]. The objectives of these programs are to reduce the need for highlighted the interest of transfusion management software as a
blood transfusion and, more particularly, to improve patient means of reducing length of stay (-4 days on average) and
outcomes, as emphasized in the recent definition of PBM mortality (from 5.5 to 3.3% - p < 0.001) [116]. That said, the level of
[104]. However, in most studies the main objective is reduced evidence remained very low.
blood transfusion, not reduced length of stay or occurrence of FIELD 3: Perioperative measures
complications. Moreover, in circumstances where practices are Coordinators: Pascal Alfonsi, Laura Ruscio
modified, randomized controlled studies are difficult to carry out. Question: Does the choice of anaesthetic agents have an
As a result, the present-day level of evidence for PBM is low to impact on the occurrence of postoperative complications and
moderate; that is why the strength of this recommendation is length of hospital stay?
GRADE 2+. Experts: Jacques de Montblanc (Paris), Pascal Alfonsi (Paris)
That said, the literature shows some positive results for PBM
programs with regard to postoperative length of hospital stay. In a R3.1 – It is not recommended to privilege a given modality of
meta-analysis carried out for a 2018 international consensus general anaesthesia (intravenous vs. inhaled; with vs. without
conference, a PBM program reduced length of stay by an average of opiates) in view of reducing length of stay and postoperative
0.5 days [102]. In an observational prospective before/after study, a complications.
PBM program in orthopaedic surgery reduced stay duration by a
median of one day, while the readmission rate at D30 decreased
from 9 to 5.8% and the complication rate was halved, declining Argumentation:
from 1.5 to 0.75% [105]. Anaesthesia by inhalation vs. total intravenous anaesthesia
In general, PBM programs are built around a set of measures, Two meta-analyses comparing the effects of inhaled and
three of which are primordial: (1) optimizing erythropoiesis, (2) intravenous anaesthesia did not show any significant difference
limiting blood loss and (3) optimizing tolerance of anemia. These in terms of length of stay [117,118]. In ambulatory surgery, two
different measures have been studied individually; there exist data randomized single-blind trials did not highlight any difference
showing the interest of the first and the third in the reduction of between the two techniques regarding the length of stay
length of stay and/or postoperative complications. [79,119]. For cardiac surgery, the 2021 SFAR-SFCTCV guidelines
As regards the first set of measures, several forms of consensus did not recommend halogenated rather than intravenous agents as
exist concerning the treatment of preoperative anemia. More means of reducing the incidence of postoperative complications
specifically, it has been recommended to preoperatively treat and duration of hospital stay [6].
anemia caused by iron deficiency [102,106–108]. It has also been Three meta-analyses have compared anaesthesia techniques as
recommended, prior to major orthopaedic surgery, to preopera- means of achieving increased survival following carcinologic
tively treat patients with hemoglobin (Hb) < 13 g/dL by surgery [120–122]. One of them found no difference [120], and
erythropoiesis (EPO) and iron [102]. Different European and while the two others were favorable to intravenous anaesthesia
American learned societies have suggested treating anemic [121,122]; however they were too heterogeneous to justify a
patients by EPO ( iron) in case of high transfusion risk, but they formal conclusion. In the framework of the present FER, a meta-
have not specified for which types of surgery [106,107]. These analysis bringing together 19 studies and including 27,594
recommendations have been given in literature showing low blood patients was carried out by the experts, and the above-mentioned
transfusion. Based on studies dealing with preoperative utilization, a results were confirmed, since in terms of postoperative survival, no
meta-analysis has highlighted a reduction of hospital stays by an difference between the two anaesthesia techniques was found: HR
average of close to three days (-2.98 days CI95% (-3.33 — -2.61) - 0.99 95%CI [0.74–1.33]; p = 0.97; I2 = 0%) (Forest plot in Appendix
p < 0.001) [109]. However, even though reduced transfusion was 1 in Supplemantary material).
reported, reduced hospital stay was not found in a meta-analysis Concerning increased recurrence-free survival following carci-
comparing ‘‘iron + EPO’’ + ‘‘iron alone’’ [110]. A recent randomized nologic surgery, one meta-analysis found higher recurrence-free
controlled study comparing IV iron administration to a placebo in survival using intravenous anaesthesia (albeit with sizable
treatment of preoperative anemia (Hb < 13 g/dL) independently of heterogeneity) [121], while another did not highlight any
an iron deficiency diagnosis revealed no benefit of IV iron alone with significant difference [122]. The meta-analysis based on 13 studies
regard to length of stay or postoperative complications [111]. That (16,982 patients) carried out by the experts in the framework of
said, intravenous iron administration led to increased volumes of the present FER did not find any difference between the two
postoperative Hb and decreased rates of postoperative readmission anaesthesia techniques in terms of recurrence-free survival: HR
(RR 0.61 (0.40-0.91)) [111]. In several recent meta-analyses 1.02 [0.73–1.43]; p = 0.93 ; I2 = 0%) (Forest plot in the Appendix
[112,113], preoperative treatment by IV iron likewise seemed to 1 in Supplemantary material).
yield improved postoperative Hb or to shorten anemia correction Lastly, a meta-analysis with a low level of evidence concluded
time, without modifying length of stay. However, anemia is known to that the frequency of postoperative cognitive disorders in elderly
have a negative impact on rehabilitation. A multicenter randomized subjects is lower with intravenous anaesthesia [118]. Conversely, a
controlled study demonstrated that compared to customary man- randomized single centre trial did not highlight any difference
agement, treatment of postoperative anemia (Hb from 7.5 to 12 g/dL between the two techniques in terms of cognitive dysfunction in
on postoperative D1) by 1g of ferric carboxymaltose could reduce elderly subjects with cancer at the 7th day or the 3rd month
hospital stay, postoperative complications and physical fatigue at 4 to subsequent to surgery [123]. Nor did analysis of the literature
8 weeks after the operation [114]. show one technique to be more beneficial than the other, in terms
As regards the third set of measures, in a randomized study of occurrence of pulmonary complications [124].
implementation of restrictive transfusion strategies through To conclude, in the present-day state of knowledge, total
training and digitizing of the transfusion prescription with regular intravenous anaesthesia may possibly be more effective than
updating of the key indicators (transfusion rate, transfusion inhaled anaesthesia, but only as a means of reducing the frequency
thresholds) helped to reduce hospital stays by an average of of postoperative cognitive disorders in elderly ‘‘at risk’’ patients.
1.6 days; the prescribers (junior doctors) had been randomized as Opioid anaesthesia (OA) vs. opioid-free anaesthesia (OFA) with
users or non-users of the software [115]. Another retrospective alpha-2 adjuvant (non-LRA)
7
Five meta-analyses compared morphine consumption 24 h Expert: Sébastien Campion (Nogent-sur-Marne)

after the operation [125–129]. As a difference is considered
clinically significant only when it reaches 10 mg of morphine- R3.3 – It is recommended to administer protective ventilation
equivalent dose, none of them revealed a difference in effective- associating tidal volume from 6 to 8 mL/kg of theoretical ideal
ness between the two strategies. body weight, positive expiratory pressure (PEP) of at least 5 cmH2O
Four meta-analyses have compared the effects of OFA and OA and iterative maneuvers of alveolar recruitment, the objective
on the incidence of postoperative nausea and/or vomiting (PONV) being to reduce the occurrence of postoperative complications in
[125–127,129]. Three of them found a sizable reduction in PLNV programmed surgery of an adult.
frequency when OFA was administered; the relative risks (RR)
ranged from 0.22 to 0.77. In all of the meta-analyses, heterogeneity
was low. Argumentation:
Two meta-analyses [126,129] and two randomized trials Conventional ventilation (CV) is defined by the application of
[130,131] evaluated the effect of dexmedetomidine on the tidal volume of at least 10 mL/kg of the ideal body weight (IBW),
frequency of bradycardia occurrence. In the two meta-analyses and without either positive expiratory pressure (PEP) or alveolar
and one of the randomized controlled trials [130], bradycardia recruitment maneuvers. Protective ventilation (PV) is defined by
frequency did not differ between OA and OFA with dexmedeto- application of a low tidal volume (6–8 mL/kg of IBW), associated
midine. By contrast, Beloeil’s randomized controlled trial was with positive expiratory pressure (PEP) and alveolar recruitment
prematurely discontinued due to the occurrence in the dexme- maneuvers.
detomidine group of five cases of severe bradycardia, including In a meta-analysis by PROVE Network, including 15 randomized
three instances of asystole [131]. The median dose of dexmede- and controlled clinical trials (n = 2127 patients), in comparison
tomidine in these patients exceeded 0.9 mg/kg/h. with CV, PV helps to reduce the incidence of postoperative
In conclusion, when compared to OA, OFA with dexmedeto- pulmonary complications (PPC) (RR 0.64 95%CI [0.46–0.88] – p <
midine reduces PONV frequency. Morphine-sparing effect at the 0.01) [136]. In a 2016 meta-analysis of three randomized clinical
24th hour is low and not clinically significant (less than 10 mg in trials including 495 patients, Yang et al. reported that patients
24 h). With OA, the duration of recovery room stay seems to be receiving perioperative PV presented fewer PPC than those
prolonged and possibly liable to delay the discharge of patients receiving CV: less pneumopathy (OR 0.21 [0.09–0.50] – p <
having undergone outpatient surgery, and no benefit has up until 0.001), less atelectasis (OR 0.15 [0.04–0.61] – p = 0.008) and less
now been clearly demonstrated with regard to the total length of respiratory distress (OR 0.36 [0.20–0.64] – p = 0.006) [137]. For
stay. the three complications, heterogeneity (I2) was nil. The authors
also observed shorter hospital stays in patients ventilated with PV
R3.2 – It is not recommended to prefer one type of anaesthesia (mean difference 2.1 days [ 3.95 to 0.2] – p = 0.03), but with
(neuraxial locoregional anaesthesia vs. general anaesthesia) in more pronounced heterogeneity for this endpoint (I2 87%).
view of reducing the length of stay and the postoperative The effect ascribable to low tidal volume, alveolar recruitment
complications in lower limb surgery. maneuvers and PEP has been separately assessed in three meta-
analyses [138–140]. Yang et al. evaluated the effect of low tidal
volume (16 randomized clinical trials including 1054 patients) and
Argumentation: observed reduced incidence of pneumopathy (OR 0.33 [0.16–0.68]
The bibliographic analysis carried out for the 2019 SFAR FER on – p < 0.001 – I2 9%) [138]. On the other hand, they found no impact
enhanced recovery after major orthopaedic lower limb surgery did on incidence of atelectasis, respiratory distress, or length of
not find neuraxial anaesthesia to be more effective than general hospital stay. In addition, a randomized trial published in
anaesthesia (recommendation G2 ) [4], nor did the analysis for 2020 comparing two ventilation strategies differing in terms of
the 2017 SFAR recommendations on anaesthesia for elderly tidal volume (6 mL/kg of IBW vs. 10 mL/kg of IBW) but both
patients, one example being fracture of the upper extremity of associating PEP at 5 cmH2O showed no difference at D7 in terms of
the femur (recommendation G1 ) [132]. A retrospective cohort PPC [141].
study of 26,871 patients having undergone a lower limb In a meta-analysis including 12 randomized controlled clinical
revascularization procedure was favorable to neuraxial locoregio- trials with a population of 2756 patients, Cui et al. observed
nal anaesthesia, with reduced mortality, cardio-pulmonary and reduced PPC (OR 0.67 [0.49–0.90] – p < 0.001) when recruitment
renal complications, and length of hospital stay [133]. More maneuvers (RM) were carried out [139]; that said, there was
recently, the multicentre randomized prospective REGAIN study considerable heterogeneity (I2 67%). In a sequential meta-analysis
(USA, Canada) of 1600 patients compared spinal neuraxial including 14 randomized controlled clinical trials with a popula-
anaesthesia (SNA) to general anaesthesia (GA) for fracture of the tion of 1238 patients, Zhang et al. did not observe beneficial effects
upper extremity of the femur and found no difference with regard of PEP (vs. zero PEP) on the incidence of atelectasis (RR 0.51 [0.10–
to the primary endpoint (inability to walk more than 3 m at D60) 2.55]) or pneumopathy (RR 0.48 [0.05–4.86]) [140]. That said, it
(18.5% after SNA vs. 18.0% after GA), even among the most fragile behooves clinicians in a perioperative setting to remain vigilant in
patients in sub-group analysis [134]. D60 mortality was identical with regard to the potentially deleterious effects of high PEP or
in the two groups (3.9% after SNA vs. 4.1% after GA). Walking alveolar recruitment maneuvers.
capacity and occurrence of postoperative delirium episodes were To conclude, the utilization of protective ventilation in a
likewise identical in the two groups. However, the secondary perioperative setting, associated with low tidal volume, positive
endpoints were favorable to the SNA group, with less renal failure expiratory pressure and recruitment maneuvers, may quite
(4.5% vs. 7.6%), intensive care admission (2.3% vs. 3.7%) and intra- possibly reduce postoperative pulmonary complications. Taken
hospital death (0.6% vs. 1.6%). After having randomized one by one, however, the different components of protective
950 patients, the RAGA study did not demonstrate SNA superiority ventilation seem less effective.
regarding the incidence of postoperative delirium [135]. Question: Does the administration of local anaesthetics by
Question: Do the modalities of ventilation during an perineural, neuro-axial, systemic or local route have an impact
operation have an impact on occurrence of postoperative on occurrence of postoperative complications or length of
complications or length of hospital stay? hospital stay?
8
Experts: Laura Ruscio (Paris), Philippe Grillo (Marseille), Sébastien R3.5 – It is recommended to carry out open airway locoregional
Campard (Nantes) anaesthesia after major thoracic or abdominal (including vascular)
surgery so as to reduce occurrence of postoperative complications.
R3.4 – It is recommended to administer local anaesthetics by the GRADE 1+ (STRONG AGREEMENT)
perineural route so as to reduce the occurrence of postoperative
R3.6 – It is probably recommended to carry out locoregional
complications in limb surgery.
anaesthesia in thoracic surgery by videothoracoscopy, as well as
GRADE 1+ (STRONG AGREEMENT) parietal thoraco-abdomino-pelvic or spinal surgery, the objective
Argumentation: being to reduce the incidence of postoperative complications.
Most of the literature on the utilization of peripheral nerve GRADE 2+ (STRONG AGREEMENT)
blocks (PNB) in an ERAS pathway involves orthopaedic surgery.
The 2019 SFAR guidelines on enhanced recovery after major Argumentation:
orthopaedic surgery of the lower limb recommended the In thoracic surgery, the SFAR ‘‘enhanced recovery after
utilization of local or locoregional anaesthesia in view of pulmonary lobectomy’’ guidelines recommend a technique of
reducing pain and morphine consumption following knee locoregional anaesthesia after lobectomy by thoracotomy (recom-
arthroplasty (recommendation G1+) [4]. As regards hip arthro- mendation G1+) or thoracoscopy (recommendation G2+) [5]. In
plasty, contradictory data in the recent literature rule out a this context and as first-line procedure, analgesia by paravertebral
conclusion [142], even if the 2021 PROSPECT guidelines block is to be preferred to epidural anaesthesia (recommendation
recommended fascia iliaca nerve block and/or local infiltration G2+). While paravertebral block remains the reference technique,
anaesthesia [143]. For fracture of the upper extremity of the erector spinae plane (ESP) has led to reduced postoperative opioid
femur, the 2017 SFAR guidelines recommended administration of consumption compared to the control and to serratus anterior
a femoral or fascia iliaca block so as to ensure postoperative block [156]. The literature permits no conclusion on the
analgesia (recommendation G2+) [132]. More recently, in a effectiveness in thoracic surgery of surgical infiltration.
meta-analysis updated in 2020 with regard to 49 randomized In open abdominal aortic surgery, a Cochrane meta-analysis
controlled trials including a total of 3061 patients, the results found an interest for epidural as compared to systemic surgery,
remained favourable to PNB utilization [144]. Compared to a with reduced pain, myocardial infarct, respiratory distress and
placebo, on a 1-to-10 scale PNBs reduced the pain related to postoperative gastrointestinal bleeding, as well as length of stay in
mobilization by 2.5 points (11 studies, n = 503 patients). PNBs intensive care; on the other hand, 30-day mortality was not
also reduced the risk of postoperative delirium (13 studies, modified [157].
n = 1072 patients) and probably the risk of pulmonary infection In visceral surgery, the 2014 SFAR guidelines on ‘‘enhanced
(3 studies, n = 131 patients) and the time to first mobilization recovery after programmed colorectal surgery’’ recommended
after surgery by 11 h (3 studies, n = 208 patients). On the other thoracic epidural anaesthesia for surgery by laparotomy in the
hand, there was no difference in terms of risk of myocardial framework of multimodal anaesthesia (recommendation G1+)
ischemia and mortality at 6 months [144]. [3]. Epidural analgesia in pancreatoduodenectomy has been
There are few data in the literature on the impact of PNBs in the associated with reduced postoperative complications (OR 0.69;
ERAS pathway for surgery of the foot and the ankle. A randomized p < 0.001), length of hospital stay ( 2.7 days; p < 0.001) and
controlled study published in 2021 showed that in ankle fracture mortality (OR 0.69; p = 0.02) [158]. Epidural analgesia in major
surgery, PNBs (sciatic or saphenous nerve block) are superior to thoraco-abdominal surgery has also been associated with reduced
spinal anaesthesia in terms of analgesic effect, opium consump- postoperative delirium in elderly patients [159]. A 2014 meta-
tion, secondary effects and patient satisfaction [145]. The analysis of 125 RCTs, all surgeries taken together, confirms the
2020 PROSPECT/ESRA meta-analysis of 2020 on hallux valgus results observed for thoracic, digestive and abdominal vascular
surgery led to the recommendation for distal nerve blocks as first- surgery, showing that compared to systemic analgesia, epidural
line treatment on account of their analgesic effect and motor- anaesthesia reduced mortality (3.1% vs. 4.9%; OR 0.60), cardiac and
sparing action [146]. pulmonary events, and postoperative gastro-intestinal symptoms
In orthopaedic surgery of the upper limb, brachial plexus block [160].
is recommended, with a high level of evidence in multimodal On the other hand, for mini-invasive laparoscopy, according to
anaesthesia. The 2019 PROSPECT guidelines for rotator cuff the literature epidural analgesia does not reduce hospitalization
surgery recommend first-line use of interscalene block [147]. It duration or complications. In mini-invasive abdominal and pelvic
has been shown that interscalene block improves postoperative surgery, the TAP block has been associated with reduced pain,
anaesthesia and reduces opioid consumption and length of opioid consumption and PONV 24 h after and operation [161], and
hospital stay [148]. Moreover, use of a catheter is likely to it also seems associated with reduced occurrence of postoperative
prolong the beneficial effects of the analgesia beyond the first chronic pain [162]. Local wound infiltration may also help to
24 postoperative hours [149]. In distal surgery of the upper limb, reduce acute postoperative pain, comparably to TAP block in
numerous procedures are carried out with locoregional anaes- certain studies [163].
thesia only, as motor-sparing PNBs are probably maximally suited In cardiac surgery, the thoracic paravertebral block facilitates
to hand surgery [150,151]. recovery after cardiac surgery [6]. While erector spinae block has
There exists little literature on the impact of PNBs in vascular shown effectiveness in reducing postoperative pain, mechanical
surgery of the limbs in the framework of an ERAS pathway ventilation time, intensive care stay and feeding resumption after
[152]. PNB is recommended for arteriovenous fistula creation in cardiac surgery [164], it has not shown superiority or equivalence
the FER guidelines of the European Society for Vascular Surgery with thoracic paravertebral block.
[153] and in the good clinical practices recommendations of the In spinal surgery, erector spinae block has helped to reduce
European Renal Association [154], insofar as it permits general morphine consumption (RR 0.33; I2 0%), pain scores, and PONV
anaesthesia along with increased arterial flow and vascular caliber, incidence 24 h after surgery (RR 0.38; I2 9%) [165]. The PROSPECT
thereby facilitating surgery and favouring fistula permeability guidelines on pain following lumbar fusion surgery recommend
[155]. surgical infiltration by local anaesthesia in the framework of a
multimodal analgesia strategy [166].
9
Lastly, in breast surgery thoracic paravertebral block is Experts: Alexandre Joosten (Paris), Olivier Huet (Brest)
associated with reduced postoperative pain bloc (4.3 2.8 vs.
2.9 2.8) and PONV incidence at 24 h [167]. Serratus anterior plane R3.8 – It is probably recommended to optimize perioperative fluid
block also helps to reduce postoperative pain and opiate consumption intake based on blood pressure and systolic ejection fraction, the
(mean difference 38.5 mg of oral morphine equivalent; I2 100%) and objective being to reduce occurrence of postoperative complica-
PONV (RR 0.32; I2 38%) [168], and seems associated with reduced risk tions and length of hospital stay.
of developing chronic pain three months and six months after
mastectomy [169]. The PROSPECT guidelines recommend locoregio-
nal analgesia and surgical infiltration for oncologic breast surgery Argumentation:
[170]. However, in their network meta-analysis (66 RCT, Haemodynamic optimization currently consists in two main
4792 patients), Wong et al. did not find local infiltration to be priorities: volume optimization and maintaining arterial blood
superior to a placebo [171]. pressure within an acceptable range of physiological variables.
These different results underline the pronounced interest of At present, optimization of perioperative fluid intake is the
postoperative locoregional anaesthesia (LRA) following thoracic objective of highly diversified practices [186]. In order to limit the
and pelvic surgery by thoracotomy or laparotomy, and probably risk of inappropriate (excessive or insufficient) intake, application
also lead to recommendation of LRA after surgery by thoracotomy of a haemodynamic optimization strategy targeted and guided by
or laparoscopy, surgery of the thoracic or abdominal wall, and an advanced system of cardiac output monitoring has been
spinal surgery. recommended by several European and American anaesthesiology
societies for patients undergoing surgery at high risk of complica-
R3.7 – It is probably recommended to perioperatively utilize tion [187,188]. The haemodynamic indexes recommended as
intravenous lidocaine in abdominal and pelvic surgery to reduce guides for volume expander prescription are measurement of
the incidence of postoperative complications. systolic ejection volume (SEV) and/or cardiac output (CO). By
applying a haemodynamic optimization protocol, a practitioner
can tailor treatments and, more specifically, prescribe volume
Argumentation: expanders and vasopressive and/or inotropic catecholamine.
Which modalities and precautions? Several studies having evaluated this approach in ‘‘high-risk’’
Lidocaine by systemic route possesses analgesic, anti-hyper- surgical patients have observed reduced incidence of postopera-
algesic and anti-inflammatory properties [172]. The SFAR guide- tive complications, associated or not with reduced length of stay in
lines on postoperative pain, updated in 2016, recommend intensive care or hospital [189,190]; that said, no study with a high
intravenous (iv) lidocaine for major abdominal-pelvic and spine level of evidence has reported reduced postoperative mortality in
surgery in adults not concomitantly receiving perineural or these patients. The eventual benefits of this strategy among
epidural analgesia so as to reduce postoperative pain (POP) and patients at ‘‘moderate’’ or ‘‘low’’ risk is more debatable [191–193].
enhance rehabilitation (recommendation G2+) [88]. An interna- The maintenance of adapted tissue infusion also depends on
tional consensus recently indicated maximum dosage and means blood pressure. Numerous observational studies have demon-
of administration in view of limiting adverse effects: initial bolus of strated the existence of a strong association between low blood
1.5 mg/kg delivered in 10 min, followed by an infusion of 1.5 mg/ pressure (hypotension) and occurrence of postoperative compli-
kg/h calculated on the basis of ideal weight; in addition, benefit- cations, many of which are renal or cardiovascular [194–
risk balance should always be assessed prior to administration of 196]. Three large-scale randomized prospect studies have also
lidocaine [173]. suggested a possible causal link between perioperative hypoten-
For what type of surgery? sion and postoperative morbidity [197–199]. It consequently
The recent literature (2016–2021) comparing continuous iv seemed reasonable to apply a tailored haemodynamic approach,
lidocaine to placebo (or absence of treatment) confirmed reduced which consisted in simultaneously optimizing vascular loading
POP and improved gastrointestinal function following iv lidocaine and mean arterial (MAP) and mean systolic pressure (MSP) in high-
infusion in colon surgery [174–176]. These beneficial effects seem risk patients, the objective being to reduce postoperative
likewise present in other instances of laparoscopic abdominal complications. Several meta-analyses have assessed the impact
surgery [177–182]. of a haemodynamic strategy combining targeted vascular loading
As regards non-digestive surgery, the PROSPECT guidelines do and vaso-active (vasopressive and/or inotropic) agents on postop-
not recommend lidocaine in continuous intravenous infusion in erative outcome following different types of surgery; all of them
spinal surgery [166,183]. Since the publication of these guidelines, reported a positive effect, whether in morbidity, mortality or
a meta-analysis including 4 RCTs (275 patients) presented a length of hospital stay. The most recent meta-analysis, pertaining
clinically non-significant reduction of pain at 48 h, with a high to 95 studies on 1,1659 patients, demonstrated that only a
degree of heterogeneity [184]. haemodynamic strategy combining targeted vascular loading and
Intraoperative iv lidocaine has also been associated with targeted utilization of vaso-active agents leads to significantly
reduced postoperative pain following cancerological breast reduced postoperative mortality [200]. It nonetheless bears
surgery (1 meta-analysis: 4 RCTs, 167 patients) [185], as well as mentioning that all these analyses show sizable heterogeneity
reduced incidence of cognitive disorders one month after cardiac of assessed protocols and, concerning their conclusions, a
surgery (1 meta-analysis: 5 RCTs, 688 patients). relatively low level of evidence. Lastly, we should bear in mind
To conclude, while the present-day data in the literature justify that some multicentre studies are negative but weakened by
a conditional recommendation of iv lidocaine in abdominal limitations [191,201].
surgery, as of now they do not justify its being recommended Development of haemodynamic optimization strategies conse-
for other types of surgery, especially insofar as there currently quently hinges on the combined utilization of haemodynamic
exists no robust study comparing iv lidocaine to peripheral blocks monitoring and treatment protocols. Thorough knowledge and
of the thoracic or abdominal wall or wound infiltration. mastery of the necessary tools are essential to the application of
Question: Does perioperative optimization of fluid intake these multimodal strategies. With the objective of improving
and blood pressure have an impact on length of hospital stay adhesion to these haemodynamic optimization protocols, the
and occurrence of postoperative complications? development of interactive tools such as decision-making support
10
and/or automated devices could contribute to the generalization of Question: Does prevention of perioperative hypothermia
these practices [202,203]. have an impact on length of hospital stay and occurrence of
Question: Does monitoring of the depth of anaesthesia and complications?
analgesia have an impact on length of hospital stay and Expert: Pascal Alfonsi (Paris)
occurrence of complications?
Expert: Morgan Leguen (Suresnes) R3.10 – It is recommended to combat perioperative hypothermia
so as to reduce occurrence of postoperative complications.
R3.9 – It is probably recommended to closely monitor depth of GRADE 1+ (STRONG AGREEMENT)
anaesthesia, particularly in patients at risk due to comorbidities or
to the operation itself, the objective being to reduce neuro- Argumentation:
cognitive postoperative complications. The 2018 SFAR formalized expert guidelines entitled ‘‘Preven-
tion of accidental perioperative hypothermia in adults in the
operating theater’’ recommended ‘‘combatting perioperative hypo-
ABSENCE OF RECOMMENDATION – The current literature on thermia in order to reduce occurrence of infectious, cardiovascular
accelerated postoperative rehabilitation does not permit issuing a complications in the anesthetized patient’’ [214]. The end-of-
recommendation on analgesia monitors. operation target temperature for all patients has been set at
Absence of Recommendation 36.5 8C and must never be less than 36 8C [214]. Since the writing
of these guidelines, two meta-analyses have assessed the impact of
perioperative hypothermia prevention on the frequency of surgical
site infections (SSI), and have observed 60% SSI reduction in
Argumentation: actively warmed patients [215,216]. In one of these meta-analyses
Over recent years, European learned societies have issued Balki et al. observed a 30% reduction in transfusion needs among
recommendations on this subject in the framework of accelerated actively warmed patients [216]. Active warming, which is defined
postoperative training programs. In 2016 and 2018, the ERAS as transmission of heat from a forced air furnace to a patient
society recommended monitoring on depth of anaesthesia, through a body surface warming system, reduces by close to 80%
whatever the tool, the objectives being to reduce the risk of the frequency of cardiovascular complications at the 24th hour in
perioperative memorization and, especially, to accelerate rehabili- patients at cardiovascular risk [216]. Active warming seems more
tation [204,205]. In 2018, this recommendation more specifically effective than maintaining core body temperature at >36 8C in
targeted elderly patients, the objective being to reduce the view of reducing the incidence of postoperative myocardial
incidence of postoperative delirium [205]. Similarly, the ESA damage [217].
recommended the monitoring of depth of anaesthesia so as avoid Question: Does the application of a specific protocol on
excessively deep anaesthesia and ‘‘burst suppression’’ [206]. Since prevention of nausea and vomiting have an impact on length of
then, several meta-analyses have been published, confirming the hospital stay?
interest of brain monitoring, whatever the modalities, as a means Experts: Marc Beaussier (Paris), Pierre Diesmunch (Strasbourg)
of reducing the occurrence of delirium in elderly patients, and have
highlighted a tendency toward reduced length of hospital stay R3.11 – It is recommended to set up a protocol for prevention of
[207,208]. While the effect of monitoring is of particular interest, postoperative nausea and vomiting in view of facilitating
whatever the general anaesthesia technique applied (intravenous postoperative rehabilitation.
or inhalation), during early awakening (spatial location; focused
responses to postoperative questions), it has failed to show a
beneficial effect with regard to more robust criteria such as length Argumentation:
of hospital stay and overall incidence of postoperative complica- Notwithstanding numerous studies and regularly updated
tions [209,210]. Two recent studies have dwelt on the effect of clinical practice recommendations [218,219], postoperative nau-
anaesthesia depth monitoring on postoperative cognitive perfor- sea and vomiting (PONV) continues to affect 30% of operated
mances and shown reduced incidence of postoperative delirium patients (up to 80% in certain ‘‘at-risk’’ groups). PONV occurrence
with reduced incidence of delayed cognitive dysfunction at one prolongs post-anaesthesia care unit (PACU) stay, delays patient
year [211]. To go further, two studies in which anaesthesia depth discharge, and increases risk of readmission after ambulatory
monitoring was applied to all patients compared deep anaesthesia surgery [219]. PONV management is of key importance in ERAS
to light anaesthesia (the terms were defined as the levels of protocols [218]. In these protocols, it is indispensable: 1) to track
anaesthesia depth measured by monitoring). In a randomized and record PONV, 2) to identify modifiable and non-modifiable risk
study, Evered et al. clearly demonstrated the advantage of light factors, 3) to lower background risk as much as possible and 4) to
anaesthesia (Bispectral Index (BIS) at 50) over deep anaesthesia adopt a validated multimodal prevention and treatment strategy.
(BIS at 35), with reduced incidence of postoperative delirium (19% Associations of anti-emetic drugs have a major but non-exclusive
vs. 28% (OR 0.58; p = 0.01)) and less alteration of cognitive role. In ambulatory surgery, prevention and treatment of PONV
functions at one year [212]. Applying a similar methodology, Short occurrence after hospital discharge are essential [220].
et al. reported less consumption of halogenated anaesthetics and Evaluation of PONV risk factors:
mean perioperative arterial pressure higher in the ‘‘BIS 50’’ as The Apfel (0 to 4) and the Koivuranta (0 to 5) scores are the most
compared with the ‘‘BIS 35’’ group, but there was no difference widely validated predictive scores for PONV [219].
concerning the primary endpoint, which was 1-year mortality In adults, the individual risk factors are: female gender, non-
[213]. smoker, past history of PONV or ‘‘travel sickness’’, youth, previous
Regarding analgesia monitoring, few tools have been suffi- nausea/vomiting induced by chemotherapy, dehydration, inade-
ciently validated and are utilizable in routine practice, and the quate preoperative or postoperative fasting. The most ‘‘at risk’’
available studies have largely to do with opioid consumption and operations are laparoscopic surgery, bariatric and gynaecological
levels of postoperative pain. As of now, no study has been surgery, and cholecystectomy.
conducted on surgeries with a program of postoperative rehabili- As regards anaesthesia techniques, general anaesthesia (GA) (as
tation. compared to locoregional anaesthesia), use of halogenated
11
anaesthetics and/or nitrous oxide (over an hour) are recognized respiratory failure necessitating mechanical ventilation (OR 0.7
PONV risk factors. Risk of PONV also increases according to GA (0.53–0.93) – p = 0.015) [228].
duration. During the postoperative period, opioid use likewise In conventional hospitalization, dexamethasone reduces length
increases PONV risk. Conversely, total intravenous anaesthesia and of hospital stay after lower limb arthroplasty ( 0.4 days ( 0.6 to
protocols without opioids, LRA and co-analgesia with non-opioid 0.2)) [229]; and after hepatic surgery ( 2.7 days ( 5.0 to 0.3) –
postoperative drugs lower PONV risk [219]. p = 0.03) and after colorectal surgery ( 1 day ( 1.7 to 0.3) –
As regards nausea and vomiting following return home after p = 0.01) [230]. In patients at high surgical risk, on the other hand,
ambulatory surgery, the five main risk factors are: female gender; dexamethasone administration does not reduce length of stay in
PONV history; age <50 years; opioid administration in PACU; comparison with a placebo (median of 27 days in the two groups)
nausea occurrence in PACU [220]. [228].
Reduction of background PONV risk: Two meta-analyses did not reveal clinically significant evidence
Reduction of background PONV risk is essentially premised on of postoperative morphine consumption following dexametha-
five measures pertaining to anaesthesia [218,219]: 1) preference of sone administration: 0.8 mg ( 1.3 to 0.4) of morphine during
LRA to GA; 2) in GA, preference of continuous propofol infusion to the first four postoperative hours [224], and a 10% reduction at H24
halogenated anaesthetics; 3) avoidance of nitrous oxide; 4) [227]. When used as an adjuvant to locoregional anaesthesia, a
maintenance of adequate perioperative fluid and caloric intake; systematic Cochrane review showed that when compared to a
5) maximum possible reduction of perioperative opioids, to be placebo, dexamethasone prolongs the sensory block by 6.7 h (5.5–
replaced by alternatives or medicinal combinations. 7.9) [231]. While the injection of perineural (vs. intravenous)
Utilization of anti-emetics: dexamethasone prolongs the analgesic effect by a median 3.8 h
By itself, no antiemetic decreases residual PONV rate by more (1.9–5.7) (p < 0.001), it does not reduce postoperative morphine
than 30%. That is why a multimodal approach toward reduction of consumption at 24h or reduce the incidence of severe pain at 48 h
residual PONV risk is called for [219,221]. The most commonly [232].
employed prophylaxis consists in the administration of dexa- As regards its innocuity, dexamethasone administration does
methasone and droperidol. For patients in the most ‘‘at risk’’ not increase infectious risk [227,233,234], risk of anastomotic leak
surgical situations, at the end of the operation, a drug in the setrone (OR 1 (0.5–2.2)) or postoperative bleeding (OR 1.4 (0.7–2.7))
family will be added [219,221]. [233]. Moreover, its administration has been associated with very
Acupuncture by stimulation of the P6 acupoint can prevent few side effects [221]. A brief glycemia increase is comparable in
PONV as effectively as an antiemetic [222], provided the relevant diabetics and non-diabetics from the 4th to the 24th hours, with a
medical teams are sufficiently trained and engaged. Prevention of low-amplitude peak at H4 after injection [235]. That said, in
perioperative dehydration and cautious moving of patients are diabetic patients it is advisable to limit the dexamethasone dose to
likewise recommended and risk-free approaches. 4 mg [236]. When administered in bolus before anaesthetic
Following failure of PONV prophylaxis, curative treatment is induction, dexamethasone can provoke anogenital pruritis in
based on administration of a different class of anti-emetics. 50% of cases, predominantly in women [237].
Question: Does perioperative administration of dexametha- Question: Does perioperative administration of tranexamic
sone have an impact on length of hospital stay and postopera- acid have an impact on duration of hospital stay and occurrence
tive complications? of complications?
Expert: Sophie Di Maria (Paris) Expert: Dominique Fletcher (Paris)
R3.12 – It is recommended to administer intravenous dexametha- R3.13 – It is recommended to perioperatively administer

sone at a dose of 4 or 8 mg in general anaesthesia so as to reduce tranexamic acid in major surgery and/or in the event of
postoperative complications, particularly postoperative nausea haemorrhagic risk, the objective being to reduce haemorrhagic
and vomiting. complications and/or perioperative and postoperative transfusion.
GRADE 1+ (STRONG AGREEMENT) GRADE 1+ (Accord Fort)
Argumentation: Argumentation:
The most widely studied glucocorticoid in this indication in a For cardiac and orthopaedic surgery (PTG, PTH), the interna-
perioperative setting is dexamethasone. Its interest is explained by tional guidelines recommend tranexamic acid (TA) as a means of
its strong power (40 times more than hydrocortisone), its reducing transfusion risk [238–241]. In orthopaedic surgery, a
prolonged duration of action (36 h half-life) and its absence of similar blood-sparing effect has been observed in cases of neck
mineralocorticoid activity. The generally applied dose is 4–8 mg fracture or multi-level spinal surgery, but not in less haemorrhagic
intravenous dexamethasone. Due to its delayed action, it is surgery like tibial osteotomy [242–244]. In cardiac surgery,
recommended to administer dexamethasone at the beginning of efficacy is similar with or without extracorporeal circulation
an intervention [223,224]. [245]. Currently available data on these two types of surgery are
Two meta-analyses [221,225] and a randomized study [226] based on several meta-analyses and large-scale randomized
have concluded that dexamethasone administration substantially controlled trials, all of which show a positive effect on periopera-
reduces the frequency of postoperative nausea and vomiting tive haemorrhage, with reduced frequency of transfusion approxi-
(PONV): 25.5% vs. 33% (NNT = 13) [225], RR 0.51 (0.44–0.57) mating 50% [238,242,246–249].
(NNT = 3) [221] and OR 0.31 (0.23–0.41) (NNT = 3.7) [226]. The literature on major vascular [250], urological [251] and
Moreover, following major abdominal (intestinal and hepatic) obstetric surgery [252] suggests reduced perioperative bleeding
surgery, preoperatively administered glucocorticoids significantly without a significant effect on transfusion or other immediate or
reduce postoperative surgical complications (OR 0.37 (0.21–0.64)) delayed complications or length of hospital stay. The data on major
[227]. While in patients undergoing major surgery, administration hepatic surgery are likewise inconclusive [253]. It is important to
of dexamethasone at a dose of 0.2 mg/kg at the end of the note that in the event of caesarean section or vaginal delivery
operation or at D1 does not reduce the incidence of severe complicated by post-partum haemorrhage, early administration
operative complications, it significantly reduces postoperative (<3 h after delivery) of TA reduces maternal mortality [254].
12
A double-blind randomized controlled trial published in R3.15 – It is recommended to monitor curarization and to comply
2022 included 114 centres in 22 countries and 9535 patients over with the formalized expert recommendations guidelines entitled
45 years of age having undergone all types of non-ambulatory ‘‘muscle reversal and relaxation in anaesthesia’’ concerning
surgery with the exception of cardiac and intracranial inter- decurarization, the objective being to reduce postoperative
ventions; those having received TA were compared to those complications.
having been given a placebo [255]. The impact of the
administration of two grams of TA 2 (1 g before and 1 g after
the operation) was assessed on the basis of two composite Argumentation:
criteria up until the 30th postoperative day: a criterion of efficacy No new data in the literature would appear to call into question
in the reducing the frequency of major or life-threatening the 2018 formalized expert recommendations conclusions on the
bleeding affecting a vital organ, and a criterion of safety including subject [265]. By avoiding the complications associated with
myocardial damage, venous and arterial thrombosis and non- residual curarization, good practices of decurarization contribute
haemorrhagic cerebrovascular accidents. In this study, TA to enhanced recovery after surgery and could even help to reduce
administration reduced by approximately 25% the occurrence length of stay, particularly in ambulatory patients.
of major bleeding (HR 0.76 CI95% (0.67–0.86); p < 0.001). This FIELD 4: Postoperative measures
benefit was also observed in orthopaedic (HR 0.70 (0.55–0.89); Coordinator: Anissa Belbachir
p < 0.004) as well as non-orthopaedic (HR 0.77 (0.67–0.90); Question: Does postoperative anaesthesia technique have an
p < 0.001) surgery. In addition, AT administration does not impact on length of hospital stay or occurrence of complica-
increase thrombotic risk, but non-inferiority was not achieved tions?
(HR 1.03 (0.92–1.15); p = 0.046). Expert: Anissa Belbachir (Paris)
The above safety-related data tend to corroborate previous
results in general surgery as well as traumatology, which show that R4.1 – It is recommended to utilize multimodal analgesia
TA has no effect favouring the occurrence of veno-arterial (CVA, associating analgesics other than morphine (AOM) with local
MI) or venous (pulmonary embolism) thrombosis anaesthetics, thereby implementing opioid-sparing pain manage-
[240,255,256]. These findings should lead to TA recommendations ment and reducing length of stay and postoperative complications.
in major operations or those entailing haemorrhagic risk, even
when major orthopaedic or cardiac surgery is not involved.
In orthopaedic surgery, the recommended dose is 1 g (15 mg/ Argumentation:
kg). Local application of TA is an effective application in The SFAR guidelines on postoperative pain, which were updated
orthopaedic surgery [257–259]. In cardiac surgery, the commonly in 2016, recommend a multimodal analgesic strategy [88]; since
utilized dose is 20 mg/kg at the start of the operation by then, its interest has repeatedly been confirmed.
intravenous route [260–262]. Stronger doses (up to 100 mg/kg) The concept of multimodal pain management is based on the
do not increase blood-sparing and do increase the risk of seizure concomitant utilization of (mainly non-opioid) analgesics and
[256]. In the recent large-scale POISE-3 international trial, which locoregional analgesia techniques, one objective being to minimize
included many types of surgery, the dose was 1 g before and 1 g opioid use and its side effects [266]. A double-blind, multicentre,
after the operation [255]. randomized prospective placebo-controlled study in colorectal
Question: Does antibiotic prophylaxis have an impact on surgery included 97 patients, among whom 47 received intrave-
length of hospital stay and occurrence of complications? nous paracetamol every six hours starting 30 min before the
Expert: Pascal Alfonsi (Paris) operation, while the other 50 received a placebo [267]. In the
paracetamol group, reduced postoperative opioid consumption
R3.14 – It is recommended to administer antibiotic prophylaxis in was observed, as was reduced ileus and length of postoperative
compliance with the indications and means of delivery specified in hospital stay. Another double-blind, multicentre, randomized
the SFAR ‘‘Antibiotic prophylaxis’’ guidelines, the objective being prospective study, which was carried out with patients having
to reduce surgical site infections. undergone major surgery requiring PCA morphine, dealt with an
association of one, two or three analgesics without morphine
(paracetamol, ketoprofen and nefopam) with PCA morphine
[268]. The association of these three analgesics with PCA morphine
Argumentation: led to significant morphine-sparing during the first 48 postopera-
Every year, surgical site infections (SSI) affect hundreds of tive hours and more effective analgesia during the first 24 h,
millions of patients throughout the world [263]. In the majority of compared to morphine alone.
cases, they are avoidable through compliance with hygiene and Multimodal analgesia is typically started preoperatively, with
asepsis rules and the application of SSI prevention measures, an association of paracetamol, a non-steroidal anti-inflammatory
including the administration of prophylactic antibiotics for drug (NSAID), and a selective cyclooxygenase-2 inhibitor (Cox2).
certain operations. The preamble to the ‘‘Antibiotic prophylaxis Perioperative locoregional anaesthesia is preferentially associated
in surgery and interventional medicine’’ guidelines points out that with these analgesics and pursued postoperatively. Implementa-
‘‘the objective of antibiotic prophylaxis is to combat bacterial tion of this protocol in digestive and urologic surgery, and also for
proliferation in view of reducing the risk of surgical site infection’’ resections and cystectomies, has led to a reduction of hospital stay
[264]. In order for antibiotic prophylaxis to be as effective as by one or two days, and to fewer complications [266].
possible, rules concerning means of delivery (posology according In a retrospective cross-sectional cohort study on orthopaedic
to weight, elapsed time for surgical incision. . .) must be observed surgery including 1,540,462 procedures, 512,393 hip prostheses
[264]. (HPT) and 1,028,069 knee prostheses), multimodal pain manage-
Question: Does the monitoring of curarization have an ment was utilized in 85.6% of the cases [269]. Patients having
impact on length of hospital stay and occurrence of compli- received an HPT and two analgesic modalities compared to those
cations? who had received morphine alone had fewer respiratory disorders
Experts: Jacques de Montblanc (Paris), Laura Ruscio (Paris) ( 19%), postoperative digestive complications ( 26%), opioid
prescriptions ( 18.5%) and reduced length of hospital stay
13
( 12.1%). In the KPT group, the results were similar. NSAID and Experts: Laurent Zieleskiewicz (Marseille), Frédéric Le Sache (Paris)
Cox2 inhibitors seemed to be the most effective means of
analgesia. R4.3 – It is probably recommended to implement postoperative
Question: Does thromboprophylaxis have an impact on measures in post-anaesthesia care units, particularly resumed
length of hospital stay and occurrence of complications? fluid intake, ambulation, withdrawal of urinary (and other)
Expert: Anne Godier (Paris) catheters, the objective being to reduce length of hospital stay
and postoperative complications.
R4.2 – It is recommended to implement thrombosis prevention GRADE 2+ (STRONG AGREEMENT)
protocols in order to reduce the risks of venous thromboembolic
events and postoperative complications. Argumentation:
As of now, there exists no randomized prospective study
The protocols include early walking, thromboprophylaxis treat-
assesing the impact of ERAS in post-anaesthesia care units on
ment and intermittent pneumatic compression for which the
length of stay or occurrence of complications. However, two
indications depend on the venous thromboembolic risk entailed by
before/after observational studies have found an association
the operation and the patient’s state of health.
between ultra-early postoperative ambulation (80 min) and
GRADE 1+ (STRONG AGREEMENT) reduced length of stay and postoperative pneumonia following
lung resection surgery [280,281].
Argumentation: Since 2011, early resumption of dietary intake (clear fluids) has
All in all, improved surgical and anaesthetic techniques and been recommended by the European Society of Anesthesiology
shorter length of hospital stay have reduced the risk of venous [282]. Among these recommendations, patients are allowed to
thromboembolic events (VTEE) [270–273]. As a result, it is possible drink according to their thirst immediately after surgery. There
to envision shorter and lighter thromboprophylaxis protocols, does not exist any minimum obligatory time lapse between
which would be based on less powerful antithrombotic molecules. postoperative awakening and fluid consumption, as soon as the
However, not enough studies with sufficient methodological rigor patient feels thirst. However, this high level of recommendation is
have been conducted to allow the comparison of classical with not based on robust bibliographic data. In 2018, Wu et al. published
lightened thromboprophylaxis schemas [274]. Moreover, ERAS a randomized study including 1735 patients and evaluating early
involves highly diversified operations, associated with variable oral hydration after laparoscopic cholecystectomy [283]. After
risks of VTEE, among patients whose venous thromboembolic risk administration of a clear liquid in the minutes following complete
factors are likewise variable, and as a result, it is not possible to awakening (3 mL/kg), the authors reported reduced frequency of
propose an all-embracing thromboprophylaxis schema. nausea/vomiting, less thirst and laryngeal discomfort, and
However, the implementation of thromboprophylaxis protocols increased satisfaction. In 2020, the same team using the same
in the framework of enhanced recovery after programmed or methodology published a randomized study on 2000 children after
emergency surgery has led to increased prescription of this form of general anaesthesia [284]. Compared a control group that was only
prophylaxis [7,8,275–278]. In large-scale studies, it has been allowed to drink at H4, the patients who absorbed fluids (5 mL/kg)
associated with reduced VTEE [279] and moderate to severe in a post-anaesthesia care unit presented with a higher level of
complications [7,8]. It bears mentioning that elastic socks and satisfaction and less feeling of thirst. Frequency of postoperative
compression stockings are no longer included in these protocols, nausea and vomiting occurrence did not differ between the two
which may or may not be associated with pharmacologic groups.
thromboprophylaxis. In the event of contraindication for the Question: Does early postoperative oral feeding have an
latter, mechanical prophylaxis may be employed. Intermittent impact on length of stay or occurrence of complications?
pneumatic compression is preferable to elastic compression [272]. Expert: Frédéric Le Sache (Paris)
Two types of venous thromboembolic risk factors are associated
with VTEE occurrence and lead to preference for classic or R4.4 – It is recommended to start oral feeding during the first
reinforced thromboprophylaxis over the above-mentioned schema: 24 postoperative hours, the objectives being to limit length of
hospital stay and occurrence of complications, including in the
- Major patient-related venous thromboembolic risk factors aftermath of intestinal anastomosis (with the exception of surgery
[270,272,273], which include: previous individual venous for oropharyngeal cancer, and in the absence of any surgical
thromboembolic event, major thrombophilia (deficit in anti- contraindication).
thrombin, C or S protein; mutation of homozygous Factor V or
homozygous Factor II or double heterozygosity), age >70 years,
obesity (BMI 30 kg/m2), active cancer (treatment during the Argumentation:
last 6 months), cardiac or respiratory insufficiency, estrogenic Two Cochrane meta-analyses published on the subject propose a
oral contraception and menopausal oral hormone therapy, threshold of 24 h to define early feeding following operations
neurological deficit <1 month (CVA, spinal cord injury), post- entailing risks of digestive complications [285,286]. The first meta-
partum (<2 months), renal insufficiency (creatinine clearance, analysis, carried out with a gynaecological population, primarily
whatever the mode of assessment <30 mL/min), patient having carcinologic (n = 631 patients - 5 RCTs), showed no difference with
preoperatively received erythropoietin (EPO); regard to postoperative nausea-vomiting, occurrence of postopera-
- Risk factors associated with complicated ERAS [270,273]: tive ileus or utilization of nasogastric tube [285]. On the other hand,
operation taking longer than expected, patient not walking the return of bowel function was more rapid in the group fed orally
during the first 24 postoperative hours or remaining in hospital during the first 24 postoperative hours, with hospital stay shortened
longer than the mean are at increased risk of VTEE. by 0.9 days ( 1.5 to 0.3); p = 0.003). Moreover, infectious
complications were less frequent in the group fed orally during the
Question: Does the implementation of postoperative opti- first 24 h (RR 0.20 (0.05–0.73); p = 0.02). The second meta-analysis,
mization measures in post-anaesthesia care units have an which dealt with visceral surgery (n = 1437 patients; 17 RCTs) found
impact on length of hospital stay or occurrence of complica- that the mean duration of stay was reduced by 2 days ( 3 to 0.9)
tions? (p < 0.001) in patients fed orally during the first 24 h [286]. On the
14
other hand, the occurrence of postoperative complications was not the literature. As regards ambulation, the definition of ‘‘early’’
modified, whether for digestive complications such as intra- differs considerably from one study to another, ranging from one
peritoneal abscess (RR 1.00 (0.26–3.80)) or anastomotic leak (RR hour to several days. That said, the most frequently used definition
0.78 (0.38–1.61)), pneumopathies (RR 0.88 (0.32–2.42)) or mortality in existing guidelines is: ambulation on the day of the operation, or
(RR 0.56 (0.21–1.52)). during the first 12 h following the operation [293–296]. As the
Other meta-analyses on the subject have been published [287– minimum distance defining ambulation is likewise poorly codified,
290]. In 2016, a meta-analysis evaluating early feeding also FER experts have arbitrarily postulated 20–80 m on the day of
reported reduced hospital stay ( 1.7 days ( 1.25 to 2.2); surgery as a target distance. What is more, variable outcomes
p < 0.01), without any difference with regard to the incidence of according to the type of patient and type of operation render the
anastomotic leakage, pneumopathies, need for nasogastric tube, elaboration of general recommendations even more difficult.
revision surgery, readmissions or mortality [287]. In 2021, a first When reading the literature since 2015 on the subject, it
meta-analysis dealt with the efficacy and safety of early oral feeding appears that early ambulation is safe and not associated with
(<24 h) following surgery for upper gastrointestinal tumours increased complications [293]. In fact, it has been assessed
(esophagectomy, gastrectomy, duodenal tumours, and pancreatec- following a very large number of operations: orthopaedic,
tomy) in 2100 patients included in 15 studies, among whom abdominal, thoracic, spinal, medullar, cardiac, etc. Moreover, in
1493 were included in 12 randomized trials [288]. Nutritional certain at-risk situations such as spinal anaesthesia, arterial
intake during the first 48 h essentially consisted of clear liquids. The puncture for angiography or hospitalization in intensive care,
‘‘early feeding’’ group showed no difference in terms of postopera- there seem to be no contraindications to early ambulation [297–
tive complications (18.9% vs. 21.4%; p = 0.38). On the other hand, a 299]. The main complication reported in the literature is
reduced incidence of postoperative pneumopathies was observed in orthostatic hypotension, with incidence ranging from 14 to 40%,
the ‘‘early feeding’’ group, as was reduced hospital stay ( 1.9 days and which can prevent early ambulation in approximately 5% of
( 2.4 to 1.4); p < 0.01)). The second meta-analysis published in cases [299].
2021 was limited to gastrectomy, and the conclusions were similar Whatever its definition, in a very large number of observational
in terms of reduced hospital stay ( 1.5 days ( 1.9 to 1.1); prospective or retrospective studies, regardless of surgical
p < 0.001) and there was no observed difference concerning speciality, whether the surgery be planned or emergency, and
postoperative complications [289]. In addition, early feeding was whatever the type of patient, early deambulation is independently
associated with reduced postoperative nausea and vomiting associated with reduced length of hospital stay [295,300]. For
(PONV) and asthenia (n = 138, 2 studies). Lastly, in 2021 a example, in a cohort of patients having undergone major thoracic,
systematic review including 2517 patients included in studies of abdominal, gynaecological, urological or orthopaedic surgery,
oesophagal and gastric carcinologic surgery reported no difference Daskivich et al. showed an inverse association between the
in the occurrence of postoperative complications, while reduced number of steps taken, and the likelihood of prolonged hospital
hospital stay duration in the ‘‘early feeding’’ group was observed in stay [301]. A thousand steps during the first 48 h after the
13 out of the 14 studies under consideration [290]. operation was associated with a very high probability of reduced
A possible exception is carcinologic ENT surgery, after which length of stay. In orthopaedics, a meta-analysis of five randomized
early oral feeding may be associated with postoperative compli- studies concluded that early ambulation following total prosthesis
cations. A meta-analysis involving 20 studies (including 14 RCTs) of the hip or the knee led to a shortened hospital stay, without
including 1883 patients showed a higher frequency of pharyngo- increased complications [302]. In abdominal surgery, a random-
cutaneous fistula during the first seven days in ‘‘early feeding’’ ized study likewise reported that early ambulation led to a
patients (RR 1.56 (1.15–2.11), and RR 1.40 (0.85–2.30) when shortened hospital stay, without increased complications [303].
limited to the 14 RCTs) [291]. A meta-analysis published in 2021 An independent association between the time before early
(14 publications; 4 RCTs) [292], which included nine of the studies ambulation and reduced postoperative complications was also
already analyzed in the previous meta-analysis, highlighted found with regard to numerous surgical specialities in observa-
different results, with no difference in the occurrence of tional retrospective studies. In lumbar surgery, a retrospective
pharyngocutaneous fistula but with reduced hospital stay in study on more than 23,000 patients concluded that ambulation on
‘‘early feeding’’ patients (at 72 h after surgery) compared to ‘‘late day 0 (D0) was independently associated with reduced length of
feeding’’ (from 7 days) patients (mean standardized difference -0.8 stay, as well as a lower number of urinary infections, ileus cases
days ( 1.2 to 0.4); p = 0.003). and readmissions [294]. A retrospective analysis of a 445-patient
Question: Does early ambulation have an impact on length cohort having undergone maxillo-facial surgery likewise found an
of hospital stay and occurrence of complications? independent association between early deambulation and reduced
Expert: Laurent Zieleskiewicz (Marseille) complications and length of hospital stay [304]. In digestive
surgery, conversely, the start of ambulation more than 48 h after
R4.5.1 – It is recommended to have the patient walk at an early the surgery has been associated with increased infectious
stage, ideally during the first 12 postoperative hours, and in all complications [305]. In a cohort of 1170 patients having undergone
cases before the 24th postoperative hour, the objective being to colorectal surgery, an independent association was found between
reduce length of hospital stay. six hours of mobilization on D0, and a reduction in low-grade and
high-grade postoperative complications according to the Clavien-
Dindo classification [306].
R4.5.2 – It is probably recommended to have the patient walk, The impact of early ambulation on the postoperative prognosis
ideally during the first 12 postoperative hours, and in all cases is probably particularly pronounced in elderly, obese or comorbid
before the 24th postoperative hour, the objective being to reduce patients. A randomized study on the immediate aftermath of hip
postoperative complications. replacement surgery showed that deambulation on D0 was
GRADE 2+ (STRONG AGREEMENT) associated with shorter hospital stay and lessened dizziness,
vomiting and pain [295]. In a cohort study including 500 elderly
Argumentation: patients operated for femoral neck fracture, the time elapsed prior
The two relevant terms are ‘‘early ambulation’’ and ‘‘early to deambulation was independently associated with 1-year
mobilization’’. Different parameters render it difficult to analyze mortality, with a threshold of excessive mortality at 10 days
15
[307]. In another cohort study involving 15,000 patients operated informed during the preoperative phase about this checklist and
for fracture of the hip, undergoing surgery after more than 24 h of given a tentative discharge date, they are reassured and can begin
immobilization was an independent factor for mortality (OR 1.46 to plan for their return home. Daily use of the checklist starting on
(1.25–1.70); p < 0.001) [308]. In a study published in 2021, once the day after the operation facilitates comprehension of hospital
again after surgery for a fracture of the hip, initial deambulation management and is conducive to the active participation of
more than three days after surgery was associated with excessive patients in their recovery and to an improved degree of satisfaction
mortality at D30 with an OR at 3.87 (1.2–12.5), independently of [321]. It has been associated with reduced length of hospital stay
age and comorbidities [309]. In cardiothoracic surgery, early without increased complications or readmissions. While the
deambulation was found to reduce atelectasis, which is itself utilization of predictive models for postoperative complications
associated with the later occurrence of pneumonia [310–312]. Fol- justifying readmission is a promising track that could help to
lowing pulmonary resection, ultra-early walking resumption (4 h) accelerate the discharge of low-risk patients, the models still need
is not only feasible but also associated with shortened hospital stay to be refined and validated [322].
[313]. Competing interests of the SFAR experts during the five years
Lastly, several observational studies have demonstrated the preceding validation by the SFAR board of directors.
feasibility of ultra-early ambulation in post-anaesthesia or P. Alfonsi declares the following competing interests related to
intensive care units, less than four hours, and even less than the present guidelines: 3M France, Edwards, MSD; and the
one hour after surgery [314]. A before/after observational study following competing interests unrelated to the present guidelines:
found a strong association between ultra-early ambulation in a Pfizer, Vifor Pharma.
PACU (80 m) and reduced incidence of postoperative pneumonia P. Diemunsch declares the following competing interests
after pulmonary resection [280]. related to the present guidelines: Laboratoire Acacia.
All in all, the positive effect of early ambulation appears well- A. Godier declares the following competing interests related to
documented and consistently validated in randomized studies. As the present guidelines: Bayer Healthcare, BMS-Pfizer, Boehringer
regard the impact of early ambulation on occurrence of compli- Ingelheim, Sanofi; and the following competing interests unrelated
cations, while the association is practically certain, the relation of to the present guidelines: Aguettant, Alexion, CSL Behring, LFB,
cause and effect is probable, but difficult to demonstrate. For Octapharma.
example, this type of linkage was not found in the main meta- A. Joosten declares the following competing interests related to
analysis highlighting the reduced length of hospital stay [302]. The the present guidelines: consultant pour Edwards Lifesciences and
effect of early ambulation probably varies according to elapsed Fresenius Kabi.
time, type of patient, and distance covered. Future studies are S. Lasocki declares the following competing interests related to
needed in order to specify these parameters and achieve better the present guidelines: remunerated lectures and funding for
personalization of early post-surgical ambulation [315]. It would research projects by Vifor Pharma, remunerated lectures by Pfizer,
seem advisable to provide staff (physiotherapists) dedicated to paid congress participation and research support by Pharmacos-
early patient ambulation. mos; and the following competing interests unrelated to the
Question: Does utilization of a list of criteria for hospital present guidelines: remunerated lectures by Masimo.
discharge have an impact on length of hospital stay and F. Le Sache declares no competing interest related to the present
occurrence of complications? guidelines, and declares the following competing interests
Expert: Yên-Lan Nguyen (Paris) unrelated to the present guidelines: BBraun, Gamida, General
Electric.
R4.6 – It is probably recommended to establish a list of criteria for E. Weiss declares no competing interest related to the present
hospital discharge, the objective being to reduce length of stay, guidelines, and declares the following competing interests
without affecting occurrence of postoperative complications. unrelated to the present guidelines: lecturer for MSD and LFB.
S. Bloc, A. Belbachir, M. Beaussier, L. Bouvet, S. Campard, S.
Campion, L. Cazenave, S. Di Maria, G. Dufour, S. Fabri, D. Fletcher,
Argumentation: M. Garnier, P. Grillo, O. Huet, M. Le Guen, I. Macquer, C. Marquis, J.
On the European scale, France is one of the countries with the de Montblanc, A. Maurice-Szamburski, Y-L. Nguyen, L. Ruscio, L.
longest postoperative length of stay [316]. There exists no high Zieleskiewicz et A. Caillard have no competing interests that could
level of evidence concerning the potential interest in a list of compromise their independence with regard to the present
criteria for postoperative hospital discharge. A nationwide Dutch guidelines.
study found no association between the establishment of a
treatment procedure designed to facilitate discharge under
Appendix A. Supplementary data
optimal conditions and reduced length of hospital stay; that said,
the study methodology did not allow conclusions to be drawn on Supplementary material related to this article can be found, in
benefits found in structures showing high compliance with the the online version, at doi:https://doi.org/10.1016/j.accpm.2023.
procedure. Whether in medicine or surgery, hospital discharge is 101264.
often delayed, and in many cases, patients do not really understand
the underlying reasons. Transmission of discharge-related infor-
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Anaesthesia Critical Care & Pain Medicine

Guidelines on perioperative optimization protocol for the adult patient

Organizing society: Société Française d’Anesthésie et de Introduction

General organization Does a pre-habilitation program prior to surgery have an impact

anxious before surgery. No beneﬁt was found in terms of the Argumentation:

Five meta-analyses compared morphine consumption 24 h Expert: Sébastien Campion (Nogent-sur-Marne)

R3.12 – It is recommended to administer intravenous dexametha- R3.13 – It is recommended to perioperatively administer

You might also like

Guia 14279 230705 081935

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Guia 14279 230705 081935

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Copyright

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Guia 14279 230705 081935

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Anaesth Crit Care Pain Med (2023) 101264

Contents lists available at ScienceDirect

Anaesthesia Critical Care & Pain Medicine

Guidelines on perioperative optimization protocol for the adult patient

Organizing society: Société Française d’Anesthésie et de Introduction

General organization  Does a pre-habilitation program prior to surgery have an impact

anxious before surgery. No beneﬁt was found in terms of the Argumentation:

Five meta-analyses compared morphine consumption 24 h Expert: Sébastien Campion (Nogent-sur-Marne)

R3.12 – It is recommended to administer intravenous dexametha- R3.13 – It is recommended to perioperatively administer

You might also like

General organization Does a pre-habilitation program prior to surgery have an impact