ANESTHESIOLOGENDAGEN ABSTRACTBOEK

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1 A ANESTHESIOLOGENDAGEN 2015 ABSTRACTBOEK

2 DONDERDAG 28 MEI uur / zaal 0.5 Best of 4 (10 minuten presentatie, 5 minuten discussie) T.C.D. Rettig Intraoperative blood pressure and change in renal function after major abdominal surgery B. Brand Arterial waveform analysis cardiac output measurement and dynamic preload assessment in patients with impaired left ventricular function: a prospective, observational study. mw. S.J.A. Pans VTGM op OK is het écht nodig? mw. E.B.J. Hijenen Experiences of a training program in surgical and percutaneous cricothyrotomy techniques. VRIJDAG 29 MEI (5 minuten presentatie, 5 minuten discussie) GROEP uur / zaal 0.5 J.A. Kok Preventing postoperative LIMA-spasm using nitroglycerine during coronary artery bypass grafting surgery (CABG): a systematic review of randomized controlled trials. M. Jansen The influence of perioperative blood transfusion on duration of ventilation and hospital stay in elective isolated aortic valve surgery T. Wolvetang Knowledge on Malignant Hyperthermia: As Rare as the Disease? dr. R.M.A.W. van Wijk mw. A.S. Koene Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy Preliminary results of a first in human study of ABP-700: a novel soft etomidate intravenous anesthetic GROEP uur / zaal 0.9 mw. M.G.J. Schouten mw. C.G. Nijenhuis The effect of analgesics on metastasis in experimental cancer models: A systematic review and meta-analysis Twenty-five milligrams of s-ketamine at induction reduces early postoperative pain in fast track bariatric surgery. A pilot study. N. van Helmond The impact of extended perioperative cyclooxygenase-2 inhibition (COX-2i) on central sensitisation after breast cancer surgery M. Habraken Loco-regional anesthesia during surgery? A patient decision aid mw. J.A. Sterkenburg ClearSight Non-Invasive Beat-to-Beat Finger Blood Pressure versus Radial Artery Blood Pressure during Elective Anesthesia K. van der Sloot Intra-operative Imaging of Intestinal Microcirculation. Results of an Observational Study. GROEP uur / zaal 0.5 mw. M.A. van der Jagt AIOSen en counseling: opleiden 2.0? mw. M.L. Buis Defining the learning curve for endotracheal intubation using direct laryngoscopy: a systematic review. R.G. Lettinga Ontwerp van een Simulatietraining: lijstjes leren of context trainen? mw. A.J.R. De Bie Dekker Improving checklist usage on the ICU: making it electronic and dynamic. mw. M.S. Frijlink mw. L. Boonstra Perioperatieve briefing verbetert het teamklimaat van operatieteams The availability, condition and employability of Automated External Defibrillators in large city centres in the Netherlands

3 Voordrachten: best of 4 Intraoperative blood pressure and change in renal function after major abdominal surgery T.C.D. Rettig, E. Vermeulen, I.M. Dijkstra, P.G. Noordzij Sint Antonius Ziekenhuis Approximately 7% of all patients that undergo non-cardiac surgery suffer from postoperative renal injury. One of the proposed mechanisms for the development of postoperative renal injury is a reduced renal blood flow due to low intraoperative blood pressure. However, despite some large retrospective analyses the role of intraoperative blood pressure in the development of postoperative renal injury is still unclear. In this prospective observational study the association of intraoperative blood pressure and postoperative change in renal function was investigated in patients undergoing elective major abdominal surgery. Total intraoperative time spent below several absolute and relative mean arterial pressure (MAP) thresholds was determined for each patient. Estimated glomerular filtration rate (egfr) was determined on the day of surgery and on the 1st, 3rd and 7th postoperative day. Postoperative change in renal function was defined as a percentage of baseline egfr value. Multivariate linear regression analysis was used to adjust for confounders. Six hundred ninety egfr measurements were performed in 202 patients. One hundred thirty patients (64.4%) suffered from a decline in renal function within 7 days of surgery (mean egfr change -8.5%±18.2%). In univariate analysis absolute MAP thresholds of less than 75, 70, 65, 60 and 55mmHg and a decrease in MAP of 20, 25, 30, 35, 40 and 45% from baseline (Figure 1a) were related with a reduced egfr after surgery. After adjustment for age, sex, duration of surgery, operative blood loss and fluid balance, none of the absolute and relative MAP thresholds (Figure 1b) were associated with postoperative change in renal function. We did not observe an association between intraoperative blood pressure and postoperative change in renal function.

4 Voordrachten: best of 4 Arterial waveform analysis cardiac output measurement and dynamic preload assessment in patients with impaired left ventricular function: a prospective, observational study B. Brand, L.J. Montenij, J.P.C. Sonneveld, A.P. Nierich, W.F. Buhre, E.E.C. de Waal, Isala klnieken Universitair Medisch Centrum Utrecht Maastricht University Medical Centre Arterial waveform analysis enables minimally invasive and continuous measurement of cardiac output (CO) and dynamic preload assessment. The validity in patients with impaired left ventricular function is however less established, while these patients may benefit the most from advanced hemodynamic monitoring. Twenty-two patients scheduled for elective CABG with a left ventricular ejection fraction of 40% received a fluid challenge in the period between induction of anesthesia and sternotomy. Arterial pressure CO (APCO) and stroke volume variation (SVV) was measured before and after the fluid challenge using the FloTrac/Vigileo system, together with pulmonary artery thermodilution CO (TDCO). Patients were considered fluid responsive if TDCO increased with 15%. The following outcome measures and statistical analyses were considered: - accuracy and precision of APCO against TDCO (Bland-Altman analysis); - trending ability of APCO (concordance and polar analysis); - diagnostic accuracy of SVV (receiver operating characteristics (ROC) analysis, sensitivity, specificity, and the ideal SVV cut-off value). Bland Altman analysis revealed a bias of -0.7 L min-1 for pooled data, with limits of agreement (LOA) of -2.9 to 1.5 L min-1 (mean error 55%). Proportional bias and spread were present, which means that bias and LOA were underestimated in the high CO values. Fourquadrant concordance was 86%. Polar plot analysis revealed an angular bias of 13 degrees and radial LOA of [-55;51] degrees. ROC analysis showed an area under the curve of 0.70 (p=0.13) for SVV. The ideal cut-off value for SVV was 10%, with a sensitivity and specificity of 56% and 69% respectively. In patients with impaired left ventricular function, APCO was not interchangeable with TDCO, and the diagnostic accuracy of SVV to predict fluid responsiveness was poor.

5 Voordrachten: best of 4 VTGM op OK is het écht nodig? S.J.A. Pans, E. Molmans, S.C. Marczinski, D.G. Snijdelaar Ziekenhuis Gelderse Vallei, Ede Uges et al. toonden aan dat de microbiologische contaminatie van bereidingen voor intraveneuze toediening op verpleegafdelingen daalt van 41% naar 4% wanneer gewerkt wordt via een 'Voor Toediening Gereed Maken'-protocol (VTGM). Op basis hiervan vereist de IGZ dat deze bereidingen, ook die op OK, volgens dit protocol worden gereed gemaakt. Echter, in tegenstelling tot de verpleegafdelingen, is op de OK luchtbehandeling aanwezig en werkt het personeel in OK-kleding met hoofdbedekking. Zover bekend zijn er geen data over de contaminatiegraad van de bereidingen voor intraveneuze toediening op OK. Om deze reden hebben wij de contaminatiegraad bepaald van deze bereidingen op OK. Vijfenveertig anesthesiemedewerkers hebben op verschillende momenten in een periode van tien weken, in totaal 1000 injectiespuiten opgetrokken uit ampullen met 10ml steriele bouillon. De medewerkers werden gevraagd het aanprikpunt te desinfecteren met 70% alcohol daar de bouillonampullen werden aangeleverd met een niet-steriel aanprikpunt. Verder pasten de medewerkers hun gewoonlijke bereidingsmethode toe, welke mogelijk nu nog op bepaalde punten afwijkt van het VTGM protocol. De opgetrokken spuiten werden gedurende twee weken gekweekt bij 37graden Celsius. Troebele spuiten werden aangemerkt als gecontamineerd. Met behulp van vragenlijsten werd nagegaan op welke wijze de bereidingen hadden plaatsgevonden. Zes spuiten (0,6%) waren gecontamineerd met huidflora. De medewerkers die de gecontamineerde spuiten bereidden, gebruikten dezelfde werkwijze als hun collega's, met als uitzondering dat bij 4 van de 6 gecontamineerde bereidingen het aanprikpunt toch niet was gedesinfecteerd. De contaminatiegraad van bereidingen voor intraveneuze toediening op OK is zeer laag en vergelijkbaar met de contaminatiegraad van aseptische bereidingen in de ziekenhuisapotheek. Deze resultaten verantwoorden een vereenvoudigd VTGM-protocol voor gebruik op de OK. Referentie: Uges et al. Pharm Weekbl. 2005;140(37):1162-6

6 Voordrachten: best of 4 Experiences of a training program in surgical and percutaneous cricothyrotomy techniques. L.A. Bruijstens LA 1, C.P. Bleeker 1, E. Heijnen 1, J.A.G. Bos 1, F.J.A. van den Hoogen 2, G.J. Scheffer 1, M.A.H. Steegers 1 1 Department of Anesthesiology, Pain Medicine and Palliative Care, Radboud University Medical Center, Nijmegen 2 Department of Otorhinolaryngology and Head and Neck Surgery, Radboud University Medical Center, Nijmegen In airway management, a can t intubate can t oxygenate situation is rarely encountered. Anesthesiologists are expected to be competent in creating an invasive airway. Aim of our educational program is to train in order to reduce reluctance and improve performance in cricothyrotomy. Fourteen professionals in airway management participated in a cricothyrotomy training on an animal model. They were trained to perform a surgical technique (FROVA assisted/ standard surgical; ST) and a percutaneous technique (Quicktrach II; QT). All participants performed a pre-test in both techniques. After training, they performed one post-test using their technique of choice. Technique of preference, procedural times, complications and post-training opinion regarding effect of training on threshold to start a cricothyrotomy were scored. In both pre-test groups, there was one failure. All post-test cannulas or tubes were successfully positioned in the trachea. Pre-test mean time to ventilate was 84 sec (+/- 24, n=13) for ST and 75 sec (+/- 40, n=13) for QT. Post-test mean time to ventilate was 67 sec (+/- 21, n=9) for ST and 47 sec (+/- 14, n=5) for QT. Complications occurred in pre-tests (11/14 ST versus 9/14 QT), but not in post-tests. Seven participants changed their technique of preference during the training. After training, 10/14 participants chose a surgical technique as technique of first choice. All participants agreed that training reduced the threshold to perform a cricothyrotomy. Training improves success and reduces complication rate and time to perform a cricothyrotomy on an animal model. No clear suggestion can be made on superior technique. Training both techniques can be helpful in determining the technique of preference.

7 GROEP 1 Voordrachten Preventing postoperative LIMA-spasm using nitroglycerine during coronary artery bypass grafting surgery (CABG): a systematic review of randomized controlled trials J.A. Kok, J.H. Heijmans, E.M. Maas, W.F.F.A. Buhre, J.U. Schreiber MUMC+ In the perioperative period during and after CABG -, systemic administration of vasodilators are commonly used to prevent spasm of the left internal mammary artery (LIMA). Nitroglycerine (NTG) is used in order to improve the patency rate of the LIMA and therefore prevent the myocardial ischemia. The objective of this review is to investigate the current evidence for a potential beneficial effect of NTG in the prevention of LIMA-spasm in the postoperative period after CABG-surgery. A systematic search of Medline, Embase and the Cochrane Library was performed to identify randomized controlled trials (RCTs). The following terms were used: coronary artery bypass graft, internal mammary artery, nitroglycerine, vasospasm, graft free flow. Identified studies were handselected by 3 of the authors and tested on methodological quality by using the five-point Oxford score (range 1-5). Two measurements of quantitative free bleeding graft flow (ml/min) were done during systemic application of NTG or a different vasodilator. The first measurement was after transecting the LIMA, the second just before or just after starting bypass. Data from five RCT s were analyzed (N=140). Median Oxford score was 1.8. The use of systemic NTG resulted in a significant increase in blood flow of the LIMA (p< ). In the postoperative period measurements of blood flow and documentation of myocardial ischemia were not performed. Application of systemic nitroglycerine in the pre-bypass period of CABG-surgery improved the LIMAs blood flow. Postoperative data however is not available and documentation of myocardial ischemia due to LIMA vasospasm was lacking, which supports the need for further trials in this field.

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9 GROEP 1 Voordrachten The influence of perioperative blood transfusion on duration of ventilation and hospital stay in elective isolated aortic valve surgery M. Jansen, E.L.A van Dorp, S. Meier, L.P.H.J Aarts Leidsch Universitair Medisch Centrum Perioperative blood transfusion is common during cardiac surgery and cardiopulmonary bypass. Since there seems to be an emerging link between transfusion and increased mortality and morbidity, this study explored the effects of transfusion of different blood components on thirty-day mortality, duration of ventilation and hospital stay. From Jan until Dec , we conducted a single-centre cohort-study in patients undergoing thoracic aorta surgery. From this cohort, data from patients that underwent isolated aortic valve replacement (n=60) were used for analysis. Any transfusion of erythrocytes, thrombocytes and fresh frozen plasma during surgery, as recorded into the patient data monitoring system, was used as exposure in the analysis. Thirty-day mortality, duration of stay in the ICU and hospital, and duration of mechanical ventilation were determined as primary endpoint parameters. Secondary outcomes were occurrence of perioperative ischemia, stroke, pulmonary edema, ARDS, transfusion reactions and pulmonary embolism in the immediate postoperative period. Using a Cox proportional hazards regression model, we determined association between transfusion and primary endpoints. 20 out of 60 patients received transfusion (33.3%). Transfusion with erythrocytes was significantly correlated to prolonged hospital stay (HR 2.734, p=0.025, 95% CI ) compared to patients not receiving erythrocyte transfusion. Transfusion with thrombocytes showed a trend towards longer duration of mechanical ventilation (HR 2.74, p=0.071, 95% ). Perioperative transfusion of erythrocytes was significantly correlated to longer hospital stay, but not prolonged stay in the ICU. Transfusion of thrombocytes showed a trend towards correlation with longer duration of mechanical ventilation. The number of mortalities in this study (n=2) was too small to correlate mortality to transfusion.

10 GROEP 1 Voordrachten Knowledge on Malignant Hyperthermia: As Rare as the Disease? T. Wolvetang, J. Hofland, J.J.M. Takkenberg, Respectievelijk, Erasmus MC, Radboud UMC, Eramus MC Knowledge on malignant hyperthermia (MH) expanded vastly during past decades. To assess the current level of knowledge on MH, a survey was performed among Dutch anesthesia personnel. Research questions were: What is the current general knowledge of MH; do anesthesiologists (in training) know more than (trainee) nurse anesthetists; does experience with a MH crisis and/or triggerfree anesthesia result in better knowledge score? The survey consisted of an online questionnaire, composed in relation to the available literature and European guidelines. Respondents were recruited via Dutch social media groups for anesthesia personnel. The survey entailed 12 questions, 3 assessed the respondents characteristics, 9 assessed knowledge on MH. The maximum possible score was 12 points. Pi square and anova analysis were performed with SPSS Statistical software package version 21 for statistical analysis, P <0,05 was taken to represent significance. A total of 104 (n=104) respondents entered the survey. Fifty-two subjects had no experience with MH in practice, opposed to 51 who did (1 did not specify), the latter group had a significantly higher knowledge score. Results of knowledge questions and total knowledge scores are shown in table 1. Knowledge on MH is not quite as rare as the disease, but certainly needs improvement, as evidenced by this survey. Physicians have significantly better knowledge than nurses, yet the highest average knowledge score of 4.68 out of 12 is disappointing. These observations call for improved knowledge dissemination of MH. Means by which this might be achieved is simulation education, as respondents with experience have significantly better knowledge score.

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12 GROEP 1 Voordrachten Deep neuromuscular block reduces intra-abdominal pressure requirements during laparoscopic cholecystectomy M.A.W. van Wijk, R.W. Watts, Th. Ledowski, M. Trochsler, J.L. Moran, G.W.N. Arenas, Anesthesiologie, Neuromusculaire Blokkade Laparoscopic surgery causes specific postoperative discomfort and intraoperative cardiovascular, pulmonary, and splanchnic changes. The CO2 pneumoperitoneum related intra-abdominal pressure (IAP) remains one of the main drivers of these changes. We investigated the influence of deep neuromuscular blockade (NMB) on IAP and surgical conditions. This is an open prospective single-subject design study in 20 patients (14F/6M) undergoing laparoscopic cholecystectomy. Inclusion criteria: 18 years or older, and American Society of Anesthesiologists classification 1 to 3. Under a standardised anaesthesia, with succinylcholine to facilitate intubation, lowest IAP providing adequate surgical conditions was assessed after succinylcholine had worn off without NMB and with deep NMB (post-tetanic count (PTC) <2) with rocuronium. The differences between IAP allowing for an adequate surgical field before and after administration of rocuronium were determined, as were effects of patient gender, age, and bodymass-index (BMI). All patients were reversed with sugammadex. Data were analysed using SPSS v22. Due to nonparametric distribution, IAP values before and after deep NMB were tested with the Wilcoxon signed rank test. The other data were analysed with the paired or independent samples t-test as appropriate. Mean IAP without NMB was (SD 4.49) mmhg. Immediately after achieving a deep NMB this was 7.20 (2.51). This pressure difference (deltaiap) of 5.55 mm Hg (5.08, p<0.001) dropped to 3.00 mm Hg (4.30, p<0.01) after 15 minutes (deltaiap15). Higher IAP differences were found in women compared to men. A modest inverse relationship was found between pressure difference and age. Hardly any relationship was found between BMI and IAP. We found an almost 25% lower IAP after a deep NMB compared to no block in laparoscopic cholecystectomy. Younger and female patients appear to benefit more from deep neuromuscular blockade to reduce IAP.

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14 GROEP 1 Voordrachten Preliminary results of a first in human study of ABP-700: a novel soft etomidate intravenous anesthetic. A.S. Koene, MD 1 ; A. R. Absalom, MBChB, FRCA, MD 1 ; P. Meyer, MD, PhD 1 ; I. den Daas, PhD 1, 2 ; S. Sweeney, BS 3,J. Campagna, MD, PhD 3 ; D. Grayzel, MD 4 ; M.M.R.F.Struys, MD, PhD 1 1 Department of Anesthesiology, University of Groningen, University Medical Center Groningen, The Netherlands 2 QPS Netherlands, BV, Groningen, The Netherlands 3 The Medicines Company, Parsippany, NJ, USA 4 Annovation Biopharma, Cambridge, MA, USA Introduction ABP 700 is a novel, potent, positive allosteric modulator of the GABA A receptor currently being developed for monitored anesthesia care (MAC) and/or general anesthesia. A first in human, doubleblind, placebo-controlled study in healthy subjects was designed to assess the safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of ABP 700 after a single ascending intravenous bolus dose. Methods ABP-700 was studied in 10 cohorts of 6 subjects (5:1 active to placebo) with bolus doses ranging from 0.03 mg/kg to 1.00 mg/kg. Safety assessments included clinical chemistry and hematology, cardiovascular (MAP, HR), respiratory stability (EtCO2) and adverse event monitoring (myoclonic activity, nausea, skin reactions, etc). Frequent arterial and venous blood samples of ABP-700 were collected for PK analysis. Cerebral drug effect was measured by clinical observation (OAA/S) and EEG (BIS). Results ABP-700 was generally well tolerated with minimal effect on respiratory and hemodynamic parameters and no effect on adrenal function. PK was linear and dose proportional with a terminal elimination half-life (T 1/2 ) of 10.5 min (SD=0.353) to 18.7 min (SD=6.68) for venous samples across all dose regimens. Consistent with pre-clinical observation 1, the PD effect of ABP-700 appears to be dose dependent and rapidly reversible. Conclusion A bolus of ABP-700 resulted in a dose dependent cerebral drug effect with fast onset and offset with acceptable hemodynamic and respiratory stability. Side effects were within expectations and moderate. 1 Jason A. Campagna, M.D., Ph.D., Kevin Pojasek, Ph.D., David Grayzel, M.D., John Randle, Ph.D., Douglas E. Raines, M.D.; Advancing Novel Anesthetics: Pharmacodynamic and Pharmacokinetic Studies of Cyclopropyl-methoxycarbonyl Metomidate in Dogs. Anesthesiology 2014;121(6):

15 GROEP 2 Voordrachten The effect of analgesics on metastasis in experimental cancer models: A systematic review and meta-analysis S. Groot 1, M.G.J. Schouten 1, F.J. Geessink 1,G.J. Scheffer 1, C.R. Hooijmans 2 1 Radboud University Medical Centre, Dept of Anaesthesiology, Nijmegen, Netherlands 2 Radboud University Medical Centre, SYstematic Review Centre for Laboratory animal Experimentation (SYRCLE), Nijmegen, Netherlands Pain in cancer patients is common and various classes of analgesics are used to control it. It has been stated that certain analgesics can reduce the risk of cancer metastasis (NSAIDs) and others increase that risk (opioids), but the evidence is not clear. Clarification is necessary since the mortality rate of cancer primarily depends on recurrence and metastasis. We conducted a systematic review and meta-analysis on original articles concerning the effects of analgesic treatment on metastasis in experimental cancer Four search components were used in PubMed and Embase: "analgesics", "anaesthetics", "metastasis" and "animals". We included a total of 147 studies where we extracted study characteristics and outcome data on the number and incidence of metastases. The methodological quality and bias within each study was assessed. In the meta-analysis, we included 353 comparisons between analgesic versus control treatment, 216 (± 4000 animals) on the number of and 137 (± 3000 animals) on the incidence of metastases. The studies included in our analysis predominantly involved NSAIDs or opioids. Overall, we found that treatment with analgesics significantly decreased the number and risk of metastasis. NSAIDs proved to be the most potent inhibitors, whereas opioids did not appear to be effective. We also noted methodological factors that influence efficacy, such as species, type of NSAIDs administered, timing and duration of the treatment. We found a positive correlation between NSAIDs and reduced number and incidence of metastases in experimental cancer models. Opioids neither increased nor reduced the risk or number of metastasis. It is possible that the effect of NSAIDs is primarily a result of reduced inflammation via COX inhibition. Furthermore, our findings appear to be robust irrespective of the varied animal models and designs included in this review.

16 GROEP 2 Voordrachten Twenty-five milligrams of s-ketamine at induction reduces early postoperative pain in fast track bariatric surgery. A pilot study C.G. Nijenhuis, R.A. Bouwman, M.P. Buise MUMC +/ CZE In our bariatric centre a fast track protocol is practiced for gastric bypass and gastric sleeve procedures. The corner stones of anesthesia management are to ensure rapid recovery and adequate postoperative analgesia to allow early mobilisation and feeding. Adverse effects of opioids may conflict with the goals of the fast track protocol, while s-ketamine has been reported to be a good adjuvant in postoperative pain management with less nausea and vomiting (PONV). In this pilot study we aim to evaluate the added value of s-ketamine as part of anesthesia management for bariatric surgery. In a study period of two month a before/after study was performed in 68 patients undergoing gastric bypass or gastric sleeve procedure. During the first month (n=41) the current anesthesia protocol, consisting of induction with propopfol, piritramide, succinylcholine supplemented with intravenous PONV prophylaxis whilst maintenance was conducted with remifentanyl and desflurane. Skin incisions were infiltrated with ropivacaïne. In the second month (n=27) 25mg of ketamine was added at induction. Postoperatively all patients received paracetamol and paracoxib. Patients in the s-ketamine group experienced less pain on arrival in the recovery (NRS 4: n=25 (61%) Control vs. n=23 (85%) Ketamine; p<0.05). At 20 minutes, 40 minutes and at discharge this reduction in perceived pain was not observed. No differences were found for PONV, agitation and time to discharge. Based on this pilot study, s-ketamine at induction reduced postoperative pain early in the recovery period without compromising the goals of the fast-track protocol for bariatric surgery. These results suggest that future studies with regard to optimal s-ketamine dose and the clinical value are warranted.

17 GROEP 2 Voordrachten The impact of extended perioperative cyclooxygenase-2 inhibition (COX-2i) on central sensitisation after breast cancer surgery N. van Helmond, M.A. Steegers, K.C. Vissers, O.H. Wilder-Smith RadboudUMC, Nijmegen Chronic pain is a challenging clinical problem after breast cancer treatment. After surgery, infammatory pain and nociceptive input from nerve injury induce central sensitisation which may play a role in the genesis of chronic pain. Using quantitative sensory testing, we tested the hypothesis that adding COX-2i to standard maximal antinociceptive treatment (paravertebral blockade) would result in less hyperalgesia after breast cancer surgery. A secondary hypothesis was that patients who developed chronic pain would exhibit more early and late postoperative hyperalgesia. 138 women for first lumpectomy/mastectomy were randomized to COX-2i (2x40mg parecoxib on day of surgery, thereafter 2x200mg celecoxib/day until day five) or placebo. Preoperatively and 1, 5, 15 days and 1, 3, 6, 12 months postoperatively, we determined pressure pain tolerance thresholds in dermatomes C6/T4/L1 and a 100mm VAS score for pain. Chronic pain patients were confirmed by VAS>30 at 12 months. We calculated the sum of pain tolerance thresholds (SOT) and analyzed change in these vs. preoperatively using RM-ANOVA with factors medication, axillary lymph node dissection (an accepted pain predictor) and chronic pain. 48 COX-2i and 46 placebo group patients completed the protocol. BMI, surgical procedure, number of axillary lymph node dissections and additional chemo- or radiotherapy were comparable between groups. Contrary to our first hypothesis, change in SOT in the COX-2i group was not different vs. placebo. Consistent with our secondary hypothesis, SOT change in chronic pain patients was negative absolutely and vs. patients without pain (main effect, p=0.002) from day 5 to 1 year postoperatively. Perioperative COX-2i appears of limited value in preventing sensitisation after breast cancer surgery. Our results suggest that sensitisation after surgery plays a pivotal role in the genesis of chronic pain after surgery. (This abstract discusses new data and results from a trial that was discussed at last year s Anesthesiologendagen. The previous talk covered preliminary results of COX-2i on VAS pain and psychological outcome measures)

18 GROEP 2 Voordrachten Loco-regional anesthesia during surgery? A patient decision aid M.A.M. Habraken, G.J. Scheffer, M.J.L. Bucx, P.F.M. Stalmeier RadboudUmc, Nijmegen The majority of thoracic and abdominal surgery is performed under general anesthesia. Additional loco-regional anesthesia changes per- and postoperative options for analgesia. Although the beneficial effects and complications of loco-regional anesthesia are known, there is no clear consensus when to apply these techniques. In the absence of guidelines, patient preferences have an important role in decision making. By developing a Patient Decision Aid, the patient is given evidence based information to support decision making. We performed a literature search in all relevant databases. International Patient Decision Aid standards (IPDAS) guidelines were used during development. The decision aid was developed keeping in mind that it is sent to the patient before the first consultation with the anesthesiologist. The literature search showed an absence of surgery- and patient characteristic- specific results of beneficial effects and complications of loco-regional anesthesia. Based on the available literature, we developed a Patient Decision Aid which provides the patient with a description of the major (dis-) advantage and complication rates of different anesthetic strategies. We developed a Patient Decision Aid regarding additional loco-regional anesthesia. It is our aim to combine the Patient Decision Aid with a pre-operative consult of the anesthesiologist. The next steps entail a feasibility and evaluation study in patient decision making.

19 GROEP 2 Voordrachten ClearSight Non-Invasive Beat-to-Beat Finger Blood Pressure versus Radial Artery Blood Pressure during Elective Anesthesia J.A. Sterkenburg, R.V. Immink Department of Anesthesiology, University Medical Center Utrecht, Utrecht, The Netherlands In 1973 Karel Wesseling developed, based on an idea of Jan Penáz, a non-invasive beat-to-beat finger blood pressure monitor (BPfin). In the next four decades various types of monitors of various manufacturers were validated and nowadays widely used all over the world. In this study we tested whether the newest generation beat-to-beat, non-invasive finger blood pressure monitor, the ClearSight monitoring system, can replace invasive radial artery blood pressure measurement (BPrad) in the operating room. In 8 patients (5 men, aged 54±20 years), BPfin (ClearSight) and BPrad (Arbocath 20 G, Hospira Inc, Lake Forest, Illinois, USA) were monitored simultaneously and ipsilaterally for one hour intraoperatively. Per patient, 10 episodes of 20 seconds were determined during which averaged systolic, diastolic and mean BPfin and BPrad were calculated. Validation conform the Association for the Advancement of Medical Instrumentation (AAMI) between BPfin against BPrad was performed. The AAMI considers a BP measuring device acceptable when accuracy and precision remain within 5±8 mmhg. Systolic BP values ranged from 90 to 155 mmhg, diastolic from 37 to 84 mmhg and mean from 51 to 110 mmhg. Accuracy and precision for systolic, diastolic and mean BPfin versus BPrad were ±14.3, -0.5±7.8 and -3.5±9.1 mmhg respectively. Based on the AAMI criteria, mean BPfin is sufficiently accurate but the precision lies just outside the AAMI criteria. Diastolic BPfin is accurate and precise. However systolic BPfin cannot be used.

20 GROEP 2 Voordrachten Intra-operative Imaging of Intestinal Microcirculation. Results of an Observational Study. K. van der Sloot, A.F.J. de Bruin, J. van Vugt, D. Boerma, B. van Ramshorst, P. Noordzij, M. van Iterson St. Antonius ziekenhuis, Nieuwegein Failed anastomotic healing in colorectal surgery leads to high morbidity and mortality. Inadequate bowel tissue perfusion is associated with inadequate anastomotic healing. Currently, vitality of bowel tissue is macroscopically assessed by the surgeon before deciding to anastomose bowel ends. Assessment (visualization and quantification) of microcirculatory perfusion using a sidestream darkfield (SDF) imaging device has been validated sublingually in previous studies. This study investigated the feasibility of bowel microcirculatory assessment during open colorectal surgery using SDF imaging. In patients undergoing open colorectal cancer surgery microcirculation of bowel serosa and sublingual tissue was visualized using SDF imaging. Per organ site three video clips were captured (as required according to round-table consensus). To describe serosal microvascular convective flow the microvascular flow index (MFI) and percentage of perfused vessels (PPV) was used. For quantification of diffusion the total vessel density (TVD) and perfused vessel density (PVD) where obtained. Microvascular analysis and calculations where done using a validated software program (Automated Vascular Analysis, Microvisiontm version 3.2). Seventeen patients were included in this study. Acquiring good quality bowel serosal images was challenging due to various factors like hand movement of the surgeon holding the SDF device, bowel tissue movement due to peristalsis or respiration and clouding of the lens. This was less challenging sublingually. Nevertheless 87% of required serosal video clips could be analyzed. (table 1). In this study we showed that visualization and quantification of serosal microcirculation during colorectal surgery is feasible. Process of visualization and quantification of serosal and sublingual microcirculation is comparable. Table 1 Bowel serosa Sublingual Perfusion MFI 2.84 ( ) SD (2.5-3) SD 0.17 PPV (%) 94 (71-100) SD (89-100) SD 0.03 Diffusion TVD (mm/mm 2 ) ( ) SD ( ) SD 5.56 PVD (mm/mm 2 ) ( ) SD ( ) SD 5.58