Showing papers in "Canadian Journal of Anaesthesia-journal Canadien D Anesthesie in 2022"

Continuous interscalene versus phrenic nerve-sparing high-thoracic erector spinae plane block for total shoulder arthroplasty: a randomized controlled trial

Abstract: The high-thoracic erector spinae plane block (HT-ESPB) has been reported as an effective analgesic modality for the shoulder region without phrenic nerve palsy. The goal of this study was to compare the HT-ESPB as a phrenic nerve-sparing alternative to an interscalene block for total shoulder arthroplasty. Thirty patients undergoing total shoulder arthroplasty at Stanford Health Care (Palo Alto, CA, USA) were enrolled in a double-blind randomized controlled trial. We randomized 28 patients to receive either an interscalene or HT-ESPB perineural catheter preoperatively; 26 patients were included in the final analysis. The study was powered for the primary outcome of incidence of hemidiaphragmatic paralysis in the postanesthesia care unit (PACU). Other outcome measures included incentive spirometry volume, brachial plexus motor and sensory exams, adverse events, pain scores, and opioid consumption. The incidence of hemidiaphragmatic paralysis in the HT-ESPB catheter group was significantly lower than in the interscalene catheter group (0/12, 0% vs 14/14, 100%; P < 0.001). No statistically significant differences were found in pain scores and opioid consumption (in oral morphine equivalents) between the interscalene and HT-ESPB groups through postoperative day (POD) 2. Nevertheless, the mean (standard deviation) point estimates for opioid consumption for the HT-ESPB group were higher than for the interscalene group in the PACU (HT-ESPB: 24.8 [26.7] mg; interscalene: 10.7 [21.7] mg) and for POD 0 (HT-ESPB: 20.5 [25.0] mg; interscalene: 6.7 [12.0] mg). In addition, cumulative postoperative opioid consumption was significantly higher at POD 0 (PACU through POD 0) in the HT-ESPB group (45.3 [39.9] mg) than in the interscalene group (16.6 [21.9] mg; P = 0.04). This study suggests that continuous HT-ESPB can be a phrenic nerve-sparing alternative to continuous interscalene brachial plexus blockade, although the latter provided superior opioid-sparing in the immediate postoperative period. This was a small sample size study, and further investigations powered to detect differences in analgesic and quality of recovery score endpoints are needed. www.ClinicalTrials.gov (NCT03807505); registered 17 January 2019.

Patient prioritization of routine and patient-reported postoperative outcome measures: a prospective, nested cross-sectional study

Abstract: Understanding which outcomes matter most and improving outcomes for the growing population of older surgical patients are top priorities for Canadian anesthesia research. Nevertheless, there is little understanding of which outcomes older surgical patients prioritize most highly. We evaluated how older people prioritized six outcomes after elective noncardiac surgery. These outcomes were recommended in core outcome sets for perioperative medicine.Following ethical approval, we conducted a prospective, nested, cross-sectional study of people one year after they had major elective noncardiac surgery. Participants were asked to rate the importance of six commonly measured outcomes (complications, length of stay, discharge disposition, days at home, disability score, and developing a new disability) on an 11-point Likert scale. Open-ended questions elicited other preferences. Pairwise comparisons were evaluated using Bayesian multivariate regression. K-means clustering identified subgroups of patients based on overall prioritization. Thematic analysis was applied to open-ended responses.One hundred and one consecutive participants responded. All outcomes scored at least 7.7/10 on average. Complications and discharge location were most highly rated, but only days at home and length of stay had substantial probability (> 99%) of being rated lower than the other four outcomes. Thematic analysis identified the need for greater procedure-specific information, support services, and physical recovery measures.Commonly recorded and recommended outcomes are reassuringly relevant to older people; however, system-related measures are less highly valued than those more directly related to health and function. Outcomes may need to be personalized to properly evaluate the success of perioperative care.RéSUMé: OBJECTIF: Pour la recherche canadienne en anesthésie, l’une des priorités absolues consiste à comprendre quelles issues comptent le plus et à améliorer les issues pour la population croissante de patients chirurgicaux plus âgés. Néanmoins, nous ne savons que peu de choses quant aux issues les plus importantes pour les patients chirurgicaux plus âgés. Nous avons évalué la façon dont les personnes âgées priorisaient six issues après une chirurgie non cardiaque non urgente. Ces issues étaient recommandées au sein d’ensembles de critères de base en médecine périopératoire. MéTHODE: Après avoir obtenu l’approbation du comité d’éthique, nous avons mené une étude prospective, imbriquée et transversale auprès de patients un an après une chirurgie majeure non cardiaque non urgente. Les participants devaient évaluer l’importance de six critères couramment mesurés (complications, durée de séjour, dispositions à la sortie, jours à la maison, score d’invalidité et développement d’une nouvelle incapacité) sur une échelle de Likert de 11 points. Les questions ouvertes ont suscité d’autres préférences. Les comparaisons par paires ont été évaluées par régression multivariée bayésienne. L’algorithme des K-moyennes a identifié des sous-groupes de patients en fonction de leur priorisation globale. L’analyse thématique a été appliquée aux réponses ouvertes. RéSULTATS: Cent un participants consécutifs ont répondu. Tous les critères ont obtenu une note d’au moins 7,7/10 en moyenne. Les complications et le lieu de sortie étaient les mieux notés, mais seuls les jours à la maison et la durée de séjour ont affiché une probabilité substantielle (> 99 %) d’être évalués moins haut que les quatre autres critères. L’analyse thématique a révélé la nécessité d’une plus grande information spécifique à l’intervention, de services de soutien et de mesures de rétablissement physique. CONCLUSION: De façon rassurante, les critères couramment enregistrés et recommandés sont pertinents pour les personnes âgées; toutefois, les mesures liées au système sont moins appréciées que celles qui sont plus directement liées à la santé et à la fonction. Il est possible que les critères dussent être personnalisés pour évaluer de façon adéquate le succès des soins périopératoires.

Efficacy of regional anesthesia techniques for postoperative analgesia in patients undergoing major oncologic breast surgeries: a systematic review and network meta-analysis of randomized controlled trials

Abstract: The optimal regional technique to control pain after breast cancer surgery remains unclear. We sought to synthesize available data from randomized controlled trials comparing pain-related outcomes following various regional techniques for major oncologic breast surgery.In a systematic review and network meta-analysis, we searched trials in PubMed, Embase Scopus, Medline, Cochrane Central and Google Scholar, from inception to 31 July 2020, for commonly used regional techniques. The primary outcome was the 24-hr resting pain score measured on a numerical rating score of 0-10. We used surface under the cumulative ranking curve (SUCRA) to establish the probability of an intervention ranking highest. The analysis was performed using the Bayesian random effects model, and effect sizes are reported as 95% credible interval (Crl). We conducted cluster-rank analysis by combining 24-hr pain ranking with 24-hr opioid use or incidence of postoperative nausea and vomiting.Seventy-nine randomized controlled trials containing 11 different interventions in 5,686 patients were included. The SUCRA values of the interventions for 24-hr resting pain score were continuous paravertebral block (0.83), serratus anterior plane block (0.76), continuous wound infusion (0.76), single-level paravertebral block (0.68), erector spinae plane block (0.59), modified pectoral block (0.49), intercostal block (0.45), multilevel paravertebral block (0.41), wound infiltration (0.33), no intervention (0.12), and placebo (0.08). When compared with placebo, the continuous paravertebral block (mean difference, 1.26; 95% Crl, 0.43 to 2.12) and serratus anterior plane block (mean difference, 1.12; 95% Crl, 0.32 to 1.9) had the highest estimated probability of decreasing 24-hr resting pain scores. Cluster ranking analysis combining 24-hr resting pain scores and opioid use showed that most regional analgesia techniques were more effective than no intervention or placebo. Nevertheless, wound infiltration and continuous wound infusion may be the least effective active interventions for reducing postoperative nausea and vomiting.Continuous paravertebral block and serratus anterior plane block had a high probability of reducing pain at 24 hr after major oncologic breast surgery. The certainty of evidence was moderate to very low. Future studies should compare different regional anesthesia techniques, including surgeon-administered techniques such as wound infiltration or catheters. Trials comparing active intervention with placebo are unlikely to change clinical practice.PROSPERO (CRD42020198244); registered 19 October 2020.RéSUMé: CONTEXTE: La technique régionale optimale pour contrôler la douleur après une chirurgie de cancer du sein n’a pas encore été clairement établie. Nous avons cherché à synthétiser les données disponibles provenant d’études randomisées contrôlées comparant les issues liées à la douleur à la suite de diverses techniques régionales pour la chirurgie mammaire oncologique majeure. MéTHODE: Dans une revue systématique et une méta-analyse de réseau, nous avons recherché les études portant sur les techniques régionales couramment utilisées dans les bases de données PubMed, Embase Scopus, Medline, Cochrane Central et Google Scholar, de leur création au 31 juillet 2020. Le critère d’évaluation principal était le score de douleur au repos à 24 heures mesuré sur une échelle d’évaluation numérique de 0 à 10. Nous avons utilisé la surface sous la courbe de classement cumulatif (SUCRA) afin d’établir la probabilité qu’une intervention soit cotée plus haut. L’analyse a été réalisée à l’aide d’un modèle bayésien à effets aléatoires, et les tailles d’effet sont rapportées comme intervalle crédible à 95 % (ICr). Nous avons effectué une analyse de classement en grappes en combinant le classement de douleur sur 24 heures avec la consommation d’opioïdes sur 24 heures ou l’incidence des nausées et vomissements postopératoires. RéSULTATS: Soixante-dix-neuf études randomisées contrôlées comportant 11 interventions différentes chez 5686 patientes ont été incluses. Les valeurs SUCRA des interventions pour le score de douleur au repos à 24 heures étaient le bloc paravertébral continu (0,83), le bloc du plan antérieur du serratus (0,76), la perfusion continue de la plaie (0,76), le bloc paravertébral à un seul niveau (0,68), le bloc du plan des muscles érecteurs du rachis (0,59), le bloc pectoral modifié (0,49), le bloc intercostal (0,45), le bloc paravertébral multiniveau (0,41), l’infiltration de plaie (0,33), l’absence d’intervention (0,12) et le placebo (0,08). Par rapport au placebo, le bloc paravertébral continu (différence moyenne, 1,26; ICr 95 %, 0,43 à 2,12) et le bloc du plan antérieur du serratus (différence moyenne, 1,12; ICr 95 %, 0,32 à 1,9) ont affiché la probabilité estimée la plus élevée de diminuer les scores de douleur au repos à 24 heures. L’analyse du classement des grappes combinant les scores de douleur au repos et la consommation d’opioïdes à 24 heures a montré que la plupart des techniques d’analgésie régionale étaient plus efficaces que l’absence d’intervention ou un placebo. Néanmoins, l’infiltration de la plaie et la perfusion continue de la plaie semblaient être les interventions actives les moins efficaces pour réduire les nausées et vomissements postopératoires. CONCLUSION: Le bloc paravertébral continu et le bloc du plan antérieur du serratus ont affiché une forte probabilité de réduire la douleur 24 heures après une chirurgie mammaire oncologique majeure. La fiabilité des données probantes allait de modérée à très faible. Les études futures devraient comparer différentes techniques d’anesthésie régionale, y compris les techniques administrées par le chirurgien telles que l’infiltration de plaie ou les cathéters. Il est peu probable que les études comparant une intervention active à un placebo modifient la pratique clinique. Enregistrement de l’étude : PROSPERO (CRD42020198244); enregistrée le 19 octobre 2020.

Factors associated with functional disability or mortality after elective noncardiac surgery: a prospective cohort study

Abstract: Preoperative prediction of functional status after surgery is essential when practicing patient-centered medicine. We aimed to evaluate the incidence and factors associated with postoperative functional disability or all-cause mortality. Secondarily, we sought to describe the trajectory of disability in this population.Adults aged ≥ 55 yr who underwent elective noncardiac surgery under general anesthesia in a tertiary care hospital were followed up one year after surgery. Pre- and intraoperative factors associated with a composite outcome of postoperative functional disability or all-cause mortality were assessed using a multiple logistic regression. The sequential changes in the 12-item World Health Organization Disability Assessment Schedule (WHODAS) 2.0 score were described and stratified by surgical invasiveness.Of the 2,921 patients included, 293 experienced postoperative functional disability (10.0%; 95% confidence interval [CI], 8.9 to 11.1) and 124 died (4.2%; 95% CI, 3.5 to 5.0). In a multiple regression model, the potentially modifiable risk factors, body mass index ≥ 30 kg·m-2 and poor preoperative nutritional status, were significantly associated with the primary composite outcome, as well as nonmodifiable factors such as age, preoperative comorbidities, and blood loss volume. Changes in the 12-item WHODAS 2.0 disability score varied between different levels of surgical invasiveness and types of surgery.Within one year after surgery, one in ten patients experienced postoperative functional disability and one in 20 died. We identified potentially modifiable factors (obesity, poor nutritional status) associated with these adverse outcomes.University Hospital Medical Information Network (UMIN000021671); registered 31 December 2015.RéSUMé: OBJECTIF: La prédiction préopératoire du statut fonctionnel après chirurgie est essentielle dans la pratique d’une médecine centrée sur le patient. Nous avons cherché à évaluer l’incidence et les facteurs associés à l’incapacité fonctionnelle ou à la mortalité toutes causes confondues en postopératoire. En deuxième lieu, nous avons cherché à décrire la trajectoire de l’incapacité dans cette population. MéTHODE: Les adultes âgés de ≥ 55 ans qui ont subi une chirurgie non cardiaque non urgente sous anesthésie générale dans un hôpital de soins tertiaires ont été suivis jusqu’à un an après leur chirurgie. Les facteurs pré- et peropératoires associés à un devenir composite d’incapacité fonctionnelle postopératoire ou de mortalité toutes causes confondues ont été évalués à l’aide d’une régression logistique multiple. Les changements séquentiels dans le score de l’outil d’évaluation de l’invalidité de l’Organisation mondiale de la Santé (WHODAS - World Health Organization Disability Assessment Schedule) version 2.0 en 12 éléments ont été décrits et stratifiés en fonction du degré invasif de la chirurgie. RéSULTATS: Sur les 2921 patients inclus, 293 ont présenté une incapacité fonctionnelle postopératoire (10,0 %; intervalle de confiance [IC] à 95 %, 8,9 à 11,1) et 124 personnes sont décédées (4,2 %; IC 95 %, 3,5 à 5,0). Dans un modèle de régression multiple, les facteurs de risque potentiellement modifiables, un indice de masse corporelle ≥ 30 kg·m-2 et un mauvais état nutritionnel préopératoire étaient significativement associés au critère d’évaluation composite principal, ainsi qu’à des facteurs non modifiables tels que l’âge, les comorbidités préopératoires et le volume de perte de sang. Les changements dans le score d’incapacité WHODAS 2.0 à 12 éléments variaient entre les différents degrés invasifs de la chirurgie et les types de chirurgie. CONCLUSION: Dans l’année qui a suivi la chirurgie, un patient sur dix a présenté une incapacité fonctionnelle postopératoire et un sur 20 est décédé. Nous avons identifié des facteurs potentiellement modifiables (obésité, mauvais état nutritionnel) associés à ces effets indésirables. ENREGISTREMENT DE L’éTUDE: University Hospital Medical Information Network (UMIN000021671); enregistré le 31 décembre 2015.

Chronic opioid use after joint replacement surgery in seniors is associated with increased healthcare utilization and costs: a historical cohort study

Abstract: Postoperative opioid use may be associated with increased healthcare utilization and costs. We sought to examine the relationship between duration of postoperative opioid prescriptions and healthcare costs and resource utilization in senior patients following hip and knee replacement. We conducted a historical cohort study evaluating postoperative opioid use and healthcare costs in patients over the age of 65 yr undergoing primary total hip or knee arthroplasty over a ten-year period from 1 April 2006 to 31 March 2016. The last follow-up date was 31 March 2017. We identified preoperative and postoperative opioid prescriptions, patient characteristics, and healthcare costs using deidentified Ontario administrative databases (Institute of Clinical Evaluative Sciences). Duration of postoperative opioid use was divided into four categories: short-term (1–90 days), prolonged (91–180 days), chronic (181–365 days), and undocumented. The study included 49,638 hip and 85,558 knee replacement patients. Although the initial hospitalization accounted for the greatest cost in all patients, over the following year patients in the short-term opioid use group incurred the lowest average costs, and those in the chronic group incurred the highest (hip, CAD 17,528 vs CAD 26,736; knee, CAD 16,043 vs CAD 23,007), driven by increased healthcare resource utilization. Chronic opioid use after arthroplasty was associated with higher resource utilization and healthcare costs during the year following surgery. These results can be used to develop predictors of longer opioid use and higher costs. Further research is planned to determine whether recently implemented opioid reduction strategies can reduce healthcare resource utilization.

Elective surgery in ankle and foot disorders—best practices for management of pain: a guideline for clinicians

Abstract: Complex elective foot and ankle surgeries are often associated with severe pain pre- and postoperatively. When inadequately managed, chronic postsurgical pain and long-term opioid use can result. As no standards currently exist, we aimed to develop best practice pain management guidelines. A local steering committee (n = 16) surveyed 116 North American foot and ankle surgeons to understand the “current state” of practice. A multidisciplinary expert panel (n = 35) was then formed consisting of orthopedic surgeons, anesthesiologists, chronic pain physicians, primary care physicians, pharmacists, registered nurses, physiotherapists, and clinical psychologists. Each expert provided up to three pain management recommendations for each of the presurgery, intraoperative, inpatient postoperative, and postdischarge periods. These preliminary recommendations were reduced, refined, and sent to the expert panel and “current state” survey respondents to create a consensus document using a Delphi process conducted from September to December 2020. One thousand four hundred and five preliminary statements were summarized into 51 statements. Strong consensus (≥ 80% respondent agreement) was achieved in 53% of statements including the following: postsurgical opioid use risk should be assessed preoperatively; opioid-naïve patients should not start opioids preoperatively unless non-opioid multimodal analgesia fails; and if opioids are prescribed at discharge, patients should receive education regarding importance of tapering opioid use. There was no consensus regarding opioid weaning preoperatively. Using multidisciplinary experts and a Delphi process, strong consensus was achieved in many areas, showing considerable agreement despite limited evidence for standardized pain management in patients undergoing complex elective foot and ankle surgery. No consensus on important issues related to opioid prescribing and cessation highlights the need for research to determine best practice.

A survey of labour epidural practices at obstetric anesthesia fellowship programs in the United States

Abstract: Labour epidural analgesia (LEA) is an evolving field. Various neuraxial techniques and dosing regimens are available to the modern obstetric anesthesia provider, allowing for significant practice variability. To begin a search for consensus on optimal care, we sought to query fellowship training practices for LEA. We conducted an electronic survey of institutions with American Council for Graduate Medical Education-accredited obstetric anesthesiology fellowship programs. We studied the frequency of epidural initiation techniques, including combined spinal epidural (CSE), dural puncture epidural, and epidural bolus. For maintenance techniques, we appraised the use of continuous epidural infusion, programmed intermittent bolus (PIEB), and patient-controlled epidural analgesia (PCEA). Of 40 institutions surveyed, we received 32 responses (80% response rate). Twenty-eight of 40 (70%) were included in the analysis. A plurality of institutions (12/28; 43%) preferred CSE, and among those who used CSE, 23/27 (85%) included intrathecal opioids. A majority of institutions used protocols with PIEB (55%), while almost all (92%) used PCEA. Most participants (88%) reported using dilute concentration maintenance infusions of 0.1% bupivacaine/ropivacaine or less. Despite significant variability in LEA practice, some clear patterns emerged in our survey, including preference for opioid-containing CSE and maintenance with PIEB, PCEA, and dilute epidural solutions.

Accidental administration of tranexamic acid into the epidural space: a case report

Abstract: Tranexamic acid administration into the epidural space has not been previously reported. We describe our experience managing and investigating a drug error involving incorrect route of tranexamic acid administration through an epidural catheter.A syringe containing tranexamic acid, intended for intravenous bolus and infusion intraoperatively using microbore tubing, was inadvertently attached to an epidural catheter via the Luer-type connector on the microbore tubing and epidural adapter.Saline lavage of the epidural space may be considered if tranexamic acid has been administered into the epidural space. Early multidisciplinary team involvement combined with repeated postevent neurologic monitoring is recommended to guide therapy. Adoption of neuraxial route-specific connectors, when available, may be warranted to reduce Luer-type misconnections.RéSUMé: OBJECTIF: L’administration d’acide tranexamique dans l’espace péridural n’a pas été rapportée auparavant. Nous décrivons notre expérience de prise en charge et d’investigation d’une erreur médicamenteuse due à une erreur dans la voie d’administration d’acide tranexamique via un cathéter péridural. CARACTéRISTIQUES CLINIQUES: Une seringue contenant de l’acide tranexamique, destinée à l’administration peropératoire intraveineuse de bolus et de perfusion via des tubulures de microcalibre, a été fixée par inadvertance à un cathéter péridural via un connecteur de type Luer sur la tubulure de microcalibre et l’adaptateur péridural. CONCLUSION: Un lavage salin de l’espace péridural peut être envisagé si de l’acide tranexamique a été administré dans l’espace péridural. La participation rapide d’une équipe multidisciplinaire combinée à un monitorage neurologique répété après l’événement sont recommandés pour guider le traitement. L’adoption de connecteurs spécifiques à la voie neuraxiale, lorsqu’ils sont disponibles, pourrait être utile pour réduire les erreurs de connexion de type Luer.

Anesthetic considerations for endovascular treatment of acute ischemic stroke

Abstract: The purpose of this Continuing Professional Development module is to provide information pertaining to anesthetic considerations and management of endovascular thrombectomy (EVT) for patients with acute ischemic stroke. Acute ischemic stroke is a devastating neurologic disorder and timely intervention is key to a good neurologic outcome. This article provides an overview of three important concepts: pathophysiology and disease characteristics of acute ischemic stroke, and the procedural and anesthetic aspects of EVT. Key considerations include recognition of stroke symptoms, timing and urgency of intervention, procedural considerations for anesthesiologists, risks and benefits of different anesthetic techniques, and a summary of recent guidelines. In particular, current recommendations for blood pressure management in this setting are reviewed. Timely intervention for patients with acute ischemic stroke is of utmost importance. Endovascular thrombectomy is a minimally invasive procedure that has evolved over recent decades and improves outcomes for selected patients with ischemic stroke. Anesthesiologists should have a good understanding of potential complications and anesthetic options. Recent randomized trials have shown that both general anesthesia and sedation are associated with good outcomes; the anesthetic approach should be individualized and may vary by institution. Careful monitoring and maintenance of hemodynamic goals are critical, as is effective communication with the multidisciplinary team.

Peak plasma concentration of total and free bupivacaine after erector spinae plane and pectointercostal fascial plane blocks

Abstract: Erector spinae plane blocks (ESPB) and pectointercostal fascial (PIFB) plane blocks are novel interfascial blocks for which local anesthetic (LA) doses and concentrations necessary to achieve safe and effective analgesia are unknown. The goal of this prospective observational study was to provide the timing (Tmax) and concentration (Cmax) of maximum total and free plasma bupivacaine after ESPB in breast surgery and after PIFB in cardiac surgery patients.Erector spinae plane blocks or PIFBs (18 patients per block; total, 36 patients) were performed with 2 mg⋅kg-1 of bupivacaine with epinephrine 5 μg⋅mL-1. Our principal outcomes were the mean or median Cmax of total and free plasma bupivacaine measured 10, 20, 30, 45, 60, 90, 180, and 240 min after LA injection using liquid chromatography with tandem mass spectrometry.For ESPB, the mean (standard deviation [SD]) total bupivacaine Cmax was 0.37 (0.12) μg⋅mL-1 (range, 0.19 to 0.64), and the median [interquartile range (IQR)] Tmax was 30 [50] min (range, 10-180). For ESPB, the mean (SD) free bupivacaine Cmax was 0.015 (0.017) μg⋅mL-1 (range, 0.003-0.067), and the median [IQR] Tmax was 30 [20] min (range, 10-120). After PIFB, mean plasma concentrations plateaued at 60-240 min. For PIFB, the mean (SD) total bupivacaine Cmax was 0.32 (0.21) μg⋅mL-1 (range, 0.14-0.95), with a median [IQR] Tmax of 120 [150] min (range, 30-240). For PIFB, the mean (SD) free bupivacaine Cmax was 0.019 (0.010) μg⋅mL-1 (range, 0.005-0.048), and the median [IQR] Tmax was 180 [120] min (range, 30-240). For both ESPB and PIFB, we observed no correlations between pharmacokinetic and demographic parameters.Total and free bupivacaine Cmax observed after ESPB and PIFB with 2 mg⋅kg-1 of bupivacaine with epinephrine 5 μg⋅mL-1 were five to twenty times lower than levels considered toxic in the literature.RéSUMé: OBJECTIF: Les blocs des muscles érecteurs du rachis (ESP) et les blocs des plans fasciaux pecto-intercostaux (PIFB) sont de nouveaux blocs interfasciaux pour lesquels les doses et les concentrations d’anesthésique local (AL) nécessaires à obtenir une analgésie sécuritaire et efficace sont inconnues. L’objectif de cette étude observationnelle prospective était de déterminer le moment d’administration (Tmax) et la concentration (Cmax) de bupivacaïne plasmatique totale et plasmatique libre maximale après un bloc ESP pour chirurgie mammaire et après un PIFB chez les patients en chirurgie cardiaque. MéTHODE: Des blocs ESP ou PIFB (18 patients par bloc; total, 36 patients) ont été réalisés avec 2 mg⋅kg-1 de bupivacaïne et 5 μg⋅mL-1 d’épinéphrine. Nos principaux critères d’évaluation étaient la Cmax moyenne ou médiane de bupivacaïne plasmatique totale et libre mesurée 10, 20, 30, 45, 60, 90, 180 et 240 min après l’injection d’AL par chromatographie liquide avec spectrométrie de masse en tandem. RéSULTATS: Pour le bloc ESP, la Cmax de bupivacaïne totale moyenne (écart type [ET]) était de 0,37 (0,12) μg⋅mL-1 (plage, 0,19 à 0,64), et le Tmax médian [écart interquartile (ÉIQ)] était de 30 [50] min (intervalle, 10–180). Pour le bloc ESP, la Cmax de bupivacaïne libre moyenne (ET) était de 0,015 (0,017) μg⋅mL-1 (plage, 0,003–0,067), et le Tmax médian [ÉIQ] était de 30 [20] min (intervalle, 10–120). Après un PIFB, les concentrations plasmatiques moyennes ont plafonné à 60–240 min. Pour le bloc PIFB, la Cmax de bupivacaïne totale moyenne (ET) était de 0,32 (0,21) μg⋅mL-1 (plage, 0,14–0,95), et le Tmax médian [ÉIQ] était de 120 [150] min (intervalle, 30–240). Pour le bloc PIFB, la Cmax de bupivacaïne libre moyenne (ET) était de 0,019 (0,010) μg⋅mL-1 (plage, 0,005–0,048), et le Tmax médian [ÉIQ] était de 180 [120] min (intervalle, 30–240). Pour le bloc ESP et le PIFB, nous n’avons observé aucune corrélation entre les paramètres pharmacocinétiques et démographiques. CONCLUSION: : Les Cmax de bupivacaïne totale et libre observées après un bloc ESP et PIFB avec 2 mg⋅kg-1 de bupivacaïne avec 5 μg⋅mL-1 d’épinéphrine étaient cinq à vingt fois plus faibles que les niveaux considérés comme toxiques dans la littérature.

Trends in opioid dispensing after common abdominal and orthopedic surgery procedures in British Columbia: a retrospective cohort analysis

Abstract: Postdischarge opioid prescriptions are reportedly much higher in Canada than in other countries. To assess potentially contributing factors, we examined trends after abdominal and orthopedic surgeries in British Columbia (BC). Using the BC Ministry of Health’s databases on physician billings, hospital discharge abstracts, and medication dispensations in community pharmacies for the period 2003–2016, we assembled a cohort of 263,056 patients who received laparoscopic appendectomy (LA, 11%), laparoscopic cholecystectomy (LC, 30%), open inguinal or femoral hernia repair (IHR, 20%), total hip arthroplasty (THA, 18%), or total knee arthroplasty (TKA, 22%). Adjusting for covariates using generalized linear modeling, we measured trends in percentages of patients dispensed opioids postdischarge (opioid rate) within 30 days after surgery, by surgery type, opioid type, prior use, surgeon, and trends in morphine milligram equivalents of first dispensations (MME) with 95% confidence intervals (CI). Opioid dispensation rates rose steadily. Mean annual increases were 1.7% in LA; 1.3% in LC; 0.8% in IHR; 0.9% in THA; and 0.8% in TKA. By 2016, rates were 69% in LA; 76% in LC; 81% in IHR; 88% in THA; and 94% in TKA. Codeine dispensations fell 2.4% (abdominal) and 3.1% (orthopedic) per year while tramadol dispensations increased 3.6% (abdominal) and 1.7% (orthopedic). Hydromorphone dispensations increased 2.9% per year (orthopedic); oxycodone was level at 22% between 2007 and 2014, but then fell. The mean MME rose 8 mg⋅yr-1 (95% CI, 7 to 9) (abdominal) and 61 mg⋅yr-1 (95% CI, 58 to 64) (orthopedic). Variation in rates was greater among abdominal than orthopedic surgeons. Rising opioid dispensation rates, together with shifts to prescribing higher MME opioids, doubled MME per patient in first dispensations postdischarge after abdominal or orthopedic surgery from 2003 to 2016 in BC.

Postoperative neurologic symptoms in the operative arm after shoulder surgery with interscalene blockade: a systematic review

Abstract: Postoperative neurologic symptoms (PONS) in the operative arm are important complications of shoulder surgery and interscalene blockade (ISB). This systematic review aimed to compare the risk of PONS between ISB and other techniques, and the relative safety of different agents used in ISB. Our systematic review followed Cochrane review methodology and was registered in PROSPERO. A search of MEDLINE (Ovid), EMBASE (Ovid), and CENTRAL (Wiley) from inception to June 2020 was completed. We included randomized or quasi-randomized trials of patients (> five years old) undergoing shoulder surgery with any ISB technique as an intervention, compared with any other nonregional or regional technique, or ISB of alternate composition or technique. The primary outcome was PONS (study author defined) assessed a minimum of one week after surgery. Fifty-five studies totalling 6,236 participants (median, 69; range, 30–910) were included. Another 422 otherwise eligible trials were excluded because PONS was not reported. Heterogeneity in when PONS was assessed (from one week to one year) and the diagnostic criteria used precluded quantitative meta-analysis. The most common PONS definition, consisting of one or more of paresthesia, sensory deficit, or motor deficit, was only used in 16/55 (29%) trials. Risk of bias was low in 5/55 (9%) trials and high in 36/55 (65%) trials, further limiting any inferences. These findings highlight the need for a standardized PONS outcome definition and follow-up time, along with routine, rigorous measurement of PONS in trials of ISB. PROSPERO (CRD42020148496); registered 10 February 2020.

New approach to assessing and addressing moral distress in intensive care unit personnel: a case study

Abstract: To test a new approach to address moral distress in intensive care unit (ICU) personnel. Using principles of participatory action research, we developed an eight-step moral conflict assessment (MCA) that guides participants in describing the behaviour that they have to implement, the effects this has on them, their current coping strategies, their values in conflict, any other concerns related to the situation, what helps and hinders the situation, new coping strategies, and the effect of the preceding steps on participants. This assessment was tested with eight ICU providers in an 11-bed community ICU. During three one-hour sessions, participants described their moral distress that was caused by the use of ongoing life-support for a patient who the team believed did not prefer this course of care, but whose family was requesting it. Participants experienced frustration and discouragement and coping strategies included speaking to colleagues and exercising. They felt that they were unable to take meaningful action to resolve this conflict. Values that were in conflict in the situation included beneficence and patient autonomy. Based on ranking of helping and hindering factors, the team proposed new strategies including improving consistency of care plans and educating patients’ family members and ICU personnel about advance care planning and end-of-life care. After completing this assessment, participants reported less stress and a greater ability to take meaningful action, including some of the proposed new strategies. We found this new approach to address moral distress in ICU personnel to be feasible and a useful tool for facilitating plans for reducing moral distress.