Research priorities in regional anaesthesia: an international Delphi study.

BACKGROUND: Regional anaesthesia use is growing worldwide, and there is an increasing emphasis on research in regional anaesthesia to improve patient outcomes. However, priorities for future study remain unclear. We therefore conducted an international research prioritisation exercise, setting the agenda for future investigators and funding bodies. METHODS: We invited members of specialist regional anaesthesia societies from six continents to propose research questions that they felt were unanswered. These were consolidated into representative indicative questions, and a literature review was undertaken to determine if any indicative questions were already answered by published work. Unanswered indicative questions entered a three-round modified Delphi process, whereby 29 experts in regional anaesthesia (representing all participating specialist societies) rated each indicative question for inclusion on a final high priority shortlist. If ≥75% of participants rated an indicative question as 'definitely' include in any round, it was accepted. Indicative questions rated as 'definitely' or 'probably' by <50% of participants in any round were excluded. Retained indicative questions were further ranked based on the rating score in the final Delphi round. The final research priorities were ratified by the Delphi expert group. RESULTS: There were 1318 responses from 516 people in the initial survey, from which 71 indicative questions were formed, of which 68 entered the modified Delphi process. Eleven 'highest priority' research questions were short listed, covering themes of pain management; training and assessment; clinical practice and efficacy; technology and equipment. CONCLUSIONS: We prioritised unanswered research questions in regional anaesthesia. These will inform a coordinated global research strategy for regional anaesthesia and direct investigators to address high-priority areas.

The Incidence and Predictors of Failed Spinal Anesthesia After Intrathecal Injection of Local Anesthetic for Cesarean Delivery: A Single-Center, 9-Year Retrospective Review.

BACKGROUND: The incidence of failed spinal anesthesia varies widely in the obstetric literature. Although many risk factors have been suggested, their relative predictive value is unknown. The primary objective of this retrospective cohort study was to determine the incidence of failed spinal anesthesia for cesarean deliveries at a tertiary care obstetric hospital, and its secondary objectives were to identify predictors of failed spinal anesthesia in the obstetrics population and quantify their relative importance in a predictive model for failure. METHODS: With local institutional ethics committee approval, a retrospective review of our hospital database identified the incidence of failed spinal anesthesia for 5361 cesarean deliveries between 2010 and 2019. We performed a multivariable analysis to assess the association of predictors with failure and a dominance analysis to assess the importance of each predictor. RESULTS: The incidence of failed spinal anesthesia requiring an alternative anesthetic was 2.1%, with conversion to general anesthesia occurring in 0.7% of surgeries. Supplemental analgesia or sedation was provided to an additional 2.0% of women. The most important predictors of a failed spinal anesthetic were previous cesarean delivery (odds ratio [OR], 11.33; 95% confidence interval [CI], 7.09-18.20; P < .001), concomitant tubal ligation (OR, 8.23; 95% CI, 3.12-19.20; P < .001), lower body mass index (BMI) (kg·m -2 , OR, 0.94; 95% CI, 0.90-0.98; P = .005), and longer surgery duration (minutes, OR, 1.02; 95% CI, 1.01-1.03; P = .006). Previous cesarean delivery was the most significant risk factor, contributing to 9.6% of the total 17% variance predicted by all predictors examined. CONCLUSIONS: Spinal anesthesia failed to provide a pain-free surgery in 4.1% of our cesarean deliveries. Previous cesarean delivery was the most important predictor of spinal failure. Other important predictors included tubal ligation, lower BMI, and longer surgery duration.

Ambulatory total hip and knee arthroplasty: a literature review and perioperative considerations.

PURPOSE: Total joint arthroplasty (TJA), particularly for the hip and knee, is one of the most commonly performed surgical procedures. The advancement/evolution of surgical and anesthesia techniques have allowed TJA to be performed on an ambulatory/same-day discharge basis. In this Continuing Professional Development module, we synthesize the perioperative evidence that may aid the development of successful ambulatory TJA pathways. SOURCE: We searched MEDLINE, Embase, CENTRAL, and the Cochrane Database of Systematic Reviews for ambulatory or fast-track TJA articles. In the absence of direct evidence for the ambulatory setting, we extrapolated the evidence from the in-patient TJA literature. PRINCIPAL FINDINGS: Patient selection encompassing patient, medical, and social factors is fundamental for successful same-day discharge of patients following TJA. Evidence for the type of intraoperative anesthesia favours neuraxial technique for achieving same day discharge criteria and reduced perioperative complications. Availability of short-acting local anesthetic for neuraxial anesthesia would affect the anesthetic choice. Nonetheless, modern general anesthesia with multimodal analgesia and antithrombotics in a well selected population can be considered. Regional analgesia forms an integral part of the multimodal analgesia regime to reduce opioid consumption and facilitate same-day hospital discharge, reducing hospital readmission. For ambulatory total knee arthroplasty, a combination of adductor canal block with local anesthetic periarticular infiltration provided is a suitable regional analgesic regimen. CONCLUSION: Anesthesia for TJA has evolved as such that same-day discharge will become the norm for selected patients. It is essential to establish pathways for early discharge to prevent adverse effects and readmission in this population. As more data are generated from an increased volume of ambulatory TJA, more robust evidence will emerge for the ideal anesthetic components to optimize outcomes.

RéSUMé: OBJECTIF: L'arthroplastie par prothèse totale (APT), en particulier de la hanche et du genou, constitue l'une des interventions chirurgicales les plus couramment pratiquées. L'avancement et l'évolution des techniques chirurgicales et d'anesthésie ont permis de réaliser une APT en ambulatoire/sur la base d'un congé le jour même. Dans ce module de développement professionnel continu, nous proposons une synthèse des données probantes périopératoires qui pourraient contribuer à l'élaboration de trajectoires réussies pour l'APT en ambulatoire. SOURCES: Nous avons réalisé des recherches dans MEDLINE, Embase, CENTRAL et dans la base de données Cochrane des revues systématiques à la recherche d'articles sur les APT ambulatoires ou accélérées. En l'absence de données probantes directes dans un contexte ambulatoire, nous avons extrapolé les données probantes à partir de la littérature sur les APT en milieu hospitalier. CONSTATATIONS PRINCIPALES: La sélection des patient·es englobant les facteurs patient·es, médicaux et sociaux est fondamentale pour un congé réussi le jour même après une APT. Les données probantes portant sur le type d'anesthésie peropératoire privilégient la technique neuraxiale pour respecter les critères de congé le jour même et réduire les complications périopératoires. La disponibilité d'un anesthésique local à courte durée d'action pour l'anesthésie neuraxiale affecterait le choix de l'anesthésique. Néanmoins, dans une population bien sélectionnée, l'anesthésie générale moderne avec analgésie multimodale et antithrombotiques peut être envisagée. L'analgésie régionale fait partie intégrante d'un régime d'analgésie multimodale visant à réduire la consommation d'opioïdes et à faciliter le congé de l'hôpital le jour même, ce qui réduit le nombre de réadmissions. En ce qui concerne l'arthroplastie totale du genou en ambulatoire, la combinaison d'un bloc du canal des adducteurs et d'une infiltration périarticulaire d'anesthésique local constitue un régime approprié d'analgésie régionale. CONCLUSION: L'anesthésie pour les APT a évolué de telle sorte que le congé le jour même deviendra la norme pour certain·es patient·es. Il est essentiel d'établir des trajectoires de congé précoce afin de prévenir les effets indésirables et la réadmission dans cette population. Au fur et à mesure que davantage de données seront générées à partir d'un volume accru d'APT en ambulatoire, des données probantes plus solides émergeront pour appuyer les composantes idéales de l'anesthésie pour optimiser les devenirs.

Epidemiological, methodological, and statistical characteristics of network meta-analysis in anaesthesia: a systematic review.

BACKGROUND: Network meta-analyses (NMAs) combine direct and indirect estimates to provide mixed (or network) estimates of effect sizes. The scientific rigour of the conduct and reporting of anaesthesia NMAs is unknown. This review assessed the epidemiological, methodological, and statistical characteristics of anaesthesia NMAs. METHODS: We searched four databases for anaesthesia NMAs and developed a 64-item checklist to evaluate NMAs. For 29 binary items, we defined compliance as 'the ratio of NMAs that was awarded a 'yes' for that item, divided by the total number of NMAs. The compliance of such binary items was reclassified as very low (≤25%), low (26-50%), fair (51-75%), and high (>75%). We amalgamated findings from 29 key items to provide specific recommendations (post hoc). We compared the compliance of NMAs in anaesthesia across 26 items, with that of cancer NMAs and Cochrane NMAs, and analysed improvement over time (post hoc). RESULTS: Among 62 included NMAs, compliance was low (26-50%) for protocol registration, use of PRISMA-NMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses for NMA), publication bias assessment, evidence appraisal, reporting of Bayesian methodology and consistency evaluation. Compliance was very low (≤25%) for bias assessment, biostatistician involvement, search specialist, and use of predefined important differences. CONCLUSIONS: Anaesthesia NMAs need improvement in their conduct and reporting. Anaesthesia journals should mandate the registration of protocols and reporting of NMAs using PRISMA-NMA. Authors should carefully assess publication bias, and use updated bias assessment tools, and evidence appraisal methods designed for NMAs. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42021227608.

Comparative efficacy and safety of non-neuraxial analgesic techniques for midline laparotomy: a systematic review and frequentist network meta-analysis of randomised controlled trials.

BACKGROUND: Fascial plane blocks provide effective analgesia after midline laparotomy; however, the most efficacious technique has not been determined. We conducted a systematic review and network meta-analysis of randomised controlled trials to synthesise the evidence with respect to pain, opioid consumption, and adverse events. METHODS: We searched Ovid MEDLINE, Embase, Cochrane Central, and Scopus databases for studies comparing commonly used non-neuraxial analgesic techniques for midline laparotomy in adult patients. The co-primary outcomes of the study were 24-h cumulative opioid consumption and 24-h resting pain score, reported as i.v. morphine equivalents and 11-point numerical rating scale, respectively. We performed a frequentist meta-analysis using a random-effects model and a cluster-rank analysis of the co-primary outcomes. RESULTS: Of 6115 studies screened, 67 eligible studies were included (n=4410). Interventions with the greatest reduction in 24-h cumulative opioid consumption compared with placebo/no intervention were single-injection quadratus lumborum block (sQLB; mean difference [MD] -16.1 mg, 95% confidence interval [CI] -29.9 to -2.3, very low certainty), continuous transversus abdominis plane block (cTAP; MD -14.0 mg, 95% CI -21.6 to -6.4, low certainty), single-injection transversus abdominis plane block (sTAP; MD -13.7 mg, 95% CI -17.4 to -10.0, low certainty), and continuous rectus sheath block (cRSB; MD -13.2 mg, 95% CI -20.3 to -6.1, low certainty). Interventions with the greatest reduction in 24-h resting pain score were cRSB (MD -1.2, 95% CI -1.8 to -0.6, low certainty), cTAP (MD -1.0, 95% CI -1.7 to -0.2, low certainty), and continuous wound infusion (cWI; MD -0.7, 95% CI -1.1 to -0.4, low certainty). Clustered-rank analysis including the co-primary outcomes showed cRSB and cTAP blocks to be the most efficacious interventions. CONCLUSIONS: Based on current evidence, continuous rectus sheath block and continuous transversus abdominis plane block were the most efficacious non-neuraxial techniques at reducing 24-h cumulative opioid consumption and 24-h resting pain scores after midline laparotomy (low certainty). Future studies should compare techniques for upper vs lower midline laparotomy and other non-midline abdominal incisions. CLINICAL TRIAL REGISTRATION: PROSPERO Registration Number: CRD42021269044.

Quality of recovery after pericapsular nerve group (PENG) block for primary total hip arthroplasty under spinal anaesthesia: a randomised controlled observer-blinded trial.

BACKGROUND: The pericapsular nerve group (PENG) block is a novel regional anaesthesia technique that has been proposed as an effective motor-sparing block for total hip arthroplasty. Recent randomised studies show conflicting results regarding the analgesic efficacy of the PENG block for total hip arthroplasty. METHODS: We conducted a randomised controlled observer-blinded single-centre superiority trial comparing the efficacy of the PENG block with no block for patients undergoing primary total hip arthroplasty under spinal anaesthesia. All subjects received multimodal analgesia consisting of paracetamol and celecoxib. The primary outcome was quality of recovery (QoR) at 24 h as measured by the QoR-15 questionnaire. RESULTS: A total of 112 participants (56 in each group) were included in the analysis. The median (inter-quartile range [IQR]) 24-h QoR-15 scores were higher in subjects who received a PENG block (132 [116-138]) compared with subjects who did not (103 [97-112]) with a median difference of 26 (95% confidence interval, 18-31; P<0.001). Similarly, QoR-15 at 48 h was higher in the PENG group, and opioid use at 24 and 48 h postoperatively was significantly lower in the PENG group. However, we did not find significant differences in pain score, distance to ambulation, or anti-emetic use at any time point. We did not observe any PENG block-related complications. CONCLUSION: Adding a PENG block to a multimodal analgesia regimen that includes paracetamol and celecoxib improves the quality of recovery and reduces opioid requirements for patients undergoing primary total hip arthroplasty under spinal anaesthesia. CLINICAL TRIAL REGISTRATION: NCT04591353.

Methodological and reporting quality assessment of network meta-analyses in anesthesiology: a systematic review and meta-epidemiological study.

PURPOSE: The scientific rigour of the conduct and reporting of anesthesiology network meta-analyses (NMAs) is unknown. This systematic review and meta-epidemiological study assessed the methodological and reporting quality of NMAs in anesthesiology. METHODS: We searched four databases, including MEDLINE, PubMed, Embase, and the Cochrane Systematic Reviews Database, for anesthesiology NMAs published from inception to October 2020. We assessed the compliance of NMAs against A Measurement Tool to Assess Systematic Reviews (AMSTAR-2), Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement for Network Meta-Analyses (PRISMA-NMA), and PRISMA checklists. We measured the compliance across various items in AMSTAR-2 and PRISMA checklists and provided recommendations to improve quality. RESULTS: Using the AMSTAR-2 rating method, 84% (52/62) of NMAs were rated "critically low." Quantitatively, the median [interquartile range] AMSTAR-2 score was 55 [44-69]%, while the PRISMA score was 70 [61-81]%. Methodological and reporting scores showed a strong correlation (R = 0.78). Anesthesiology NMAs had a higher AMSTAR-2 score and PRISMA score if they were published in higher impact factor journals (P = 0.006 and P = 0.01, respectively) or followed PRISMA-NMA reporting guidelines (P = 0.001 and P = 0.002, respectively). Network meta-analyses from China had lower scores (P < 0.001 and P < 0.001, respectively). Neither score improved over time (P = 0.69 and P = 0.67, respectively). CONCLUSION: The current study highlights numerous methodological and reporting deficiencies in anesthesiology NMAs. Although the AMSTAR tool has been used to assess the methodological quality of NMAs, dedicated tools for conducting and assessing the methodological quality of NMAs are urgently required. STUDY REGISTRATION: PROSPERO (CRD42021227997); first submitted 23 January 2021.

RéSUMé: OBJECTIF: La rigueur scientifique de la conduite et de la communication des méta-analyses en réseau (MAR) en anesthésiologie est inconnue. Cette revue systématique et étude méta-épidémiologique a évalué la qualité méthodologique et de communication des MAR en anesthésiologie. MéTHODE: Nous avons mené des recherches dans quatre bases de données, soit MEDLINE, PubMed, Embase et la base de données des revues systématiques Cochrane, pour trouver des MAR en anesthésiologie publiées depuis la création de ces bases de données jusqu'en octobre 2020. Nous avons évalué la conformité des MAR par rapport à trois outils, soit : AMSTAR-2 (outil de mesure pour évaluer les revues systématiques), PRISMA-NMA et les listes de contrôle PRISMA. Nous avons mesuré la conformité de divers éléments des listes de contrôle AMSTAR-2 et PRISMA et formulé des recommandations pour améliorer la qualité. RéSULTATS: En utilisant la méthode de notation AMSTAR-2, 84 % (52/62) des MAR ont reçu la cote « extrêmement faible ¼. Quantitativement, le score médian [écart interquartile] sur l'AMSTAR-2 était de 55 [44-69] %, tandis que le score PRISMA était de 70 [61-81] %. Les scores méthodologiques et de communication ont montré une forte corrélation (R = 0,78). Les MAR en anesthésiologie avaient un score AMSTAR-2 et un score PRISMA plus élevés si elles étaient publiées dans des revues à facteur d'impact plus élevé (P = 0,006 et P = 0,01, respectivement) ou avaient suivi les lignes directrices de PRISMA-NMA en matière de communication des résultats (P = 0,001 et P = 0,002, respectivement). Les méta-analyses en réseau provenant de Chine avaient des scores plus faibles (P < 0,001 et P < 0,001, respectivement). Aucun des deux scores ne s'est amélioré au fil du temps (P = 0,69 et P = 0,67, respectivement). CONCLUSION: La présente étude met en évidence de nombreuses lacunes méthodologiques et de communication dans les MAR en anesthésiologie. Bien que l'outil AMSTAR ait été utilisé pour évaluer la qualité méthodologique des MAR, il est urgent de disposer d'outils spécialisés pour mener des MAR et en évaluer la qualité méthodologique. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42021227997); soumis pour la première fois le 23 janvier 2021.

Preoperative assessment of postoperative delirium: a cross-sectional study of patients and anesthesiologists in Canada.

PURPOSE: We sought to evaluate 1) patient- and anesthesiologist-reported rates of postoperative delirium (POD) risk discussion during preoperative meetings, 2) patients' and anesthesiologists' ratings of the importance of POD, and 3) predictors of patient-reported discussion of POD risk during preoperative meetings. METHODS: In this multicentre two-part cross-sectional survey study, patients ≥ 65 yr scheduled to undergo elective noncardiac surgery completed a five-minute survey after preoperative anesthesia consultation. Patients were asked about their perception of POD importance, and whether they discussed or were assessed for POD risk. Anesthesiologists were surveyed using self-administered surveys circulated via institutional email lists. Anesthesiologists were asked about the frequency of POD risk assessment and discussion in older adults, tools used, and perception of POD-screening barriers. RESULTS: Four hundred and twelve (of 510 approached) patients (50% male; mean age, 73 yr) and 267 anesthesiologists (of 1,205 invited via e-mail) participated in this study conducted in five Canadian hospitals. Postoperative delirium screening and discussion was reported by 88/412 (22%) patients and 229/267 (86%) anesthesiologists. Postoperative delirium was rated as "somewhat-extremely" important by 64% of patients. A previous history of delirium, higher education, the number of daily medications, and longer surgical duration were associated with POD discussion. On average, anesthesiologists rated the importance of POD at 8/10, and 42% ranked "patient risk factors" as the top reason prompting discussion. CONCLUSION: The combined evaluation of patients' and anesthesiologists' perspectives provides valuable information on preoperative POD screening and risk assessment, and highlights areas for improvement in the current practice. Most factors we identified to be associated with higher odds of POD discussion are recognized risk factors of POD.

RéSUMé: OBJECTIF: Nous avons cherché à évaluer 1) les taux de discussion concernant le risque de delirium postopératoire (DPO) déclarés par les patient·es et les anesthésiologistes lors des rencontres préopératoires, 2) les évaluations des patient·es et des anesthésiologistes de l'importance de DPO, et 3) les prédicteurs d'une discussion telle que rapportée par les patient·es sur le risque de DPO pendant les rencontres préopératoires. MéTHODE: Dans ce sondage transversal multicentrique en deux parties, les patient·es ≥ 65 ans devant subir une chirurgie non cardiaque non urgente ont rempli un sondage de cinq minutes après la consultation d'anesthésie préopératoire. Les patient·es ont été interrogé·es sur leur perception de l'importance du DPO et si leur risque de DPO avait été discuté ou évalué. Des sondages auto-administrés ont été distribués aux anesthésiologistes via les listes de courriels institutionnelles. Ce sondage interrogeait les anesthésiologistes quant à la fréquence de l'évaluation et de la discussion des risques de DPO chez les personnes âgées, aux outils utilisés et à la perception des obstacles au dépistage de DPO. RéSULTATS: Quatre cent douze (des 510 personnes approchées) patient·es (50 % d'hommes; âge moyen, 73 ans) et 267 anesthésiologistes (sur 1205 invité·es par courriel) ont participé à cette étude menée dans cinq hôpitaux canadiens. Le dépistage et la discussion sur le delirium postopératoire ont été signalés par 88/412 (22 %) des patient·es et 229/267 (86 %) des anesthésiologistes. Le delirium postopératoire a été jugé « assez ­ extrêmement ¼ important par 64 % des patient·es. Des antécédents de delirium, des études supérieures, le nombre de médicaments quotidiens et une durée chirurgicale plus longue ont été associés à la discussion sur le DPO. En moyenne, les anesthésiologistes ont évalué l'importance du DPO à 8/10, et 42 % ont classé les « facteurs de risque liés au/à la patient·e ¼ comme la principale raison suscitant la discussion. CONCLUSION: L'évaluation combinée des points de vue des patient·es et des anesthésiologistes fournit des informations précieuses sur le dépistage préopératoire des DPO et l'évaluation des risques, et met en évidence les domaines à améliorer dans la pratique actuelle. La plupart des facteurs que nous avons identifiés comme étant associés à des probabilités plus élevées de discussion sur le DPO sont des facteurs de risque reconnus de DPO.

Reducing rebound pain severity after arthroscopic shoulder surgery under general anesthesia and interscalene block: a two-centre randomized controlled trial of pre-emptive opioid treatment compared with placebo.

PURPOSE: Although a single-injection interscalene block provides effective early postoperative analgesia following shoulder surgery, patients may experience "rebound pain" when the block resolves. Our objective was to determine if oral hydromorphone (2 mg) given six hours after a single-injection interscalene block for arthroscopic shoulder surgery leads to a clinically significant reduction in the severity of rebound pain. METHODS: After approval from research ethics boards, we conducted a two-centre, parallel-group, double-blind, randomized, placebo-controlled superiority trial. Patients received preoperative interscalene block, general anesthesia, and either hydromorphone or placebo six hours after the block. The primary outcome was the worst pain score in the first 24 hr postoperatively, measured on an 11-point (0-10) numerical rating scale. RESULTS: A total of 73 participants were randomly assigned to either the hydromorphone or placebo group. There was no statistically significant difference in the mean (standard deviation) worst pain score within 24 hr between the hydromorphone and placebo groups (6.5 [2.4] vs 5.9 [2.3]; mean difference, 0.6; 95% confidence interval, -0.5 to 1.8). Similarly, we did not find any significant difference in the pain trajectory, opioid use, or incidence of nausea and vomiting between the groups. The mean time to worst pain was 14.6 hr, and the mean time to first rescue analgesia was 11.3 hr after interscalene block. CONCLUSION: Hydromorphone 2 mg given six hours after interscalene block did not reduce the severity of rebound pain postoperatively compared with placebo in patients undergoing arthroscopic shoulder surgery. STUDY REGISTRATION: ClinicalTrials.gov (NCT02939209); registered 19 October 2016.

RéSUMé: OBJECTIF: Bien qu'un bloc interscalénique à injection unique fournisse une analgésie postopératoire précoce efficace après une chirurgie de l'épaule, les patient·es peuvent ressentir une « douleur de rebond ¼ lorsque le bloc se résorbe. Notre objectif était de déterminer si l'hydromorphone orale (2 mg) administrée six heures après une injection unique de bloc interscalénique pour une chirurgie arthroscopique de l'épaule entraînait une réduction cliniquement significative de la gravité de la douleur de rebond. MéTHODE: Après l'approbation des comités d'éthique de la recherche, nous avons mené une étude de supériorité dans deux centres, en groupes parallèles, à double insu, randomisée et contrôlée par placebo. Les patient·es ont reçu un bloc interscalénique préopératoire, une anesthésie générale et de l'hydromorphone ou un placebo six heures après le bloc. Le critère d'évaluation principal était le pire score de douleur au cours des premières 24 heures postopératoires, mesuré sur une échelle d'évaluation numérique de 11 points (0 à 10). RéSULTATS: Au total, 73 personnes ont participé à l'étude et ont été aléatoirement assignées au groupe hydromorphone ou au groupe placebo. Il n'y avait pas de différence statistiquement significative dans le score moyen (écart type) de la pire douleur dans les 24 heures entre les groupes hydromorphone et placebo (6,5 [2,4] vs 5,9 [2,3]; différence moyenne, 0,6; intervalle de confiance à 95 %, −0,5 à 1,8). De même, nous n'avons trouvé aucune différence significative dans la trajectoire de la douleur, la consommation d'opioïdes ou l'incidence de nausées et vomissements entre les groupes. Le temps moyen jusqu'à la pire douleur était de 14,6 heures, et le temps moyen jusqu'à la première analgésie de secours était de 11,3 heures après le bloc interscalénique. CONCLUSION: L'hydromorphone 2 mg administrée six heures après le bloc interscalénique n'a pas réduit la gravité de la douleur de rebond postopératoire par rapport au placebo chez les patient·es bénéficiant d'une chirurgie arthroscopique de l'épaule. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02939209); enregistrée le 19 octobre 2016.

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.

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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. STUDY REGISTRATION: 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.

Cost comparison between spinal versus general anesthesia for hip and knee arthroplasty: an incremental cost study.

PURPOSE: Wait list times for total joint arthroplasties have been growing, particularly in the aftermath of the COVID-19 pandemic. Increasing operating room (OR) efficiency by reducing OR time and associated costs while maintaining quality allows the greatest number of patients to receive care. METHODS: We used propensity score matching to compare parallel processing with spinal anesthesia in a block room vs general anesthesia in a retrospective cohort of adult patients undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). We compared perioperative costs, hospital costs, OR time intervals, and complications between the groups with nonparametric tests using an intention-to-treat approach. RESULTS: After matching, we included 636 patients (315 TKA; 321 THA). Median [interquartile range (IQR)] perioperative costs were CAD 7,417 [6,521-8,109], and hospital costs were CAD 10,293 [9,344-11,304]. Perioperative costs were not significantly different between groups (pseudo-median difference [MD], CAD -47 (95% confidence interval [CI], -214 to -130; P = 0.60); nor were total hospital costs (MD, CAD -78; 95% CI, -340 to 178; P = 0.57). Anesthesia-controlled time and total intraoperative time were significantly shorter for spinal anesthesia (MD, 14.6 min; 95% CI, 13.4 to 15.9; P < 0.001; MD, 15.9; 95% CI, 11.0 to 20.9; P < 0.001, respectively). There were no significant differences in complications. CONCLUSION: Spinal anesthesia in the context of a dedicated block room reduced both anesthesia-controlled time and total OR time. This did not translate into a reduction in incremental cost in the spinal anesthesia group.

RéSUMé: OBJECTIF: Les temps d'attente pour les arthroplasties articulaires totales ont augmenté, en particulier à la suite de la pandémie de COVID-19. Une augmentation de l'efficacité de la salle d'opération (SOP) fondée sur une réduction du temps en salle d'opération et des coûts associés, tout en maintenant la qualité, permettrait à un plus grand nombre de patients de recevoir des soins. MéTHODE: Nous avons utilisé l'appariement par score de propension pour comparer en parallèle des traitements par rachianesthésie dans une salle de bloc vs par anesthésie générale dans une cohorte rétrospective de patients adultes bénéficiant d'une arthroplastie totale de la hanche (ATH) et d'une arthroplastie totale du genou (ATG) primaires. Nous avons comparé les coûts périopératoires, les coûts hospitaliers, les intervalles de temps en SOP et les complications entre les groupes avec des tests non paramétriques en utilisant une approche d'intention de traiter. RéSULTATS: Après appariement, nous avons inclus 636 patients (315 ATG; 321 ATH). Les coûts périopératoires médians [écart interquartile (ÉIQ)] étaient de 7417 $ CA [6521 ­ 8109] et les coûts hospitaliers de 10 293 $ CA [9344 ­ 11 304]. Les coûts périopératoires n'étaient pas significativement différents entre les groupes (différence pseudomédiane [DM], −47 $ CA (intervalle de confiance à 95 % [IC], −214 à −130; P = 0,60), pas plus que les coûts hospitaliers totaux (DM, −78 $ CA; IC 95 %, −340 à 178; P = 0,57). Le temps sous anesthésie et le temps peropératoire total étaient significativement plus courts pour la rachianesthésie (DM, 14,6 min; IC 95 %, 13,4 à 15,9; P < 0,001; DM, 15,9; IC 95 %, 11,0 à 20,9; P < 0,001, respectivement). Aucune différence significative n'a été observée dans les complications. CONCLUSION: La rachianesthésie dans un contexte de salle de bloc dédiée a réduit à la fois le temps sous anesthésie et le temps total de SOP. Cela ne s'est pas traduit par une réduction du coût différentiel dans le groupe recevant une rachianesthésie.

The practice of regional anesthesia during the COVID-19 pandemic: an international survey of members of three regional anesthesia societies.

PURPOSE: To determine the preferences and attitudes of members of regional anesthesia societies during the COVID-19 pandemic. METHODS: We distributed an electronic survey to members of the American Society of Regional Anesthesia and Pain Medicine, Regional Anaesthesia-UK, and the European Society of Regional Anaesthesia & Pain Therapy. A questionnaire consisting of 19 questions was developed by a panel of experienced regional anesthesiologists and distributed by email to the participants. The survey covered the following domains: participant information, practice settings, preference for the type of anesthetic technique, the use of personal protective equipment, and oxygen therapy. RESULTS: The survey was completed by 729 participants from 73 different countries, with a response rate of 20.1% (729/3,630) for the number of emails opened and 8.5% (729/8,572) for the number of emails sent. Most respondents (87.7%) identified as anesthesia staff (faculty or consultant) and practiced obstetric and non-obstetric anesthesia (55.3%). The practice of regional anesthesia either expanded or remained the same, with only 2% of respondents decreasing their use compared with the pre-pandemic period. The top reasons for an increase in the use of regional anesthesia was to reduce the need for an aerosol-generating medical procedure and to reduce the risk of possible complications to patients. The most common reason for decreased use of regional anesthesia was the risk of urgent conversion to general anesthesia. Approximately 70% of the responders used airborne precautions when providing care to a patient under regional anesthesia. The most common oxygen delivery method was nasal prongs (cannula) with a surgical mask layered over it (61%). CONCLUSIONS: Given the perceived benefits of regional over general anesthesia, approximately half of the members of three regional anesthesia societies seem to have expanded their use of regional anesthesia techniques during the initial surge of the COVID-19 pandemic.

RéSUMé: OBJECTIF: Déterminer les préférences et les attitudes des membres des sociétés d'anesthésie régionale pendant la pandémie de COVID-19. MéTHODE: Nous avons distribué un sondage électronique aux membres de l'American Society of Regional Anesthesia and Pain Medicine, de Regional Anesthesia-UK et de l'European Society of Regional Anaesthesia & Pain Therapy. Un questionnaire composé de 19 questions a été élaboré par un panel d'anesthésiologistes régionaux d'expérience et distribué par courriel aux participants. Le sondage couvrait les domaines suivants : les renseignements sur les participants, les contextes de pratique, leur préférence quant au type de technique d'anesthésie, l'utilisation d'équipement de protection individuelle et l'oxygénothérapie RéSULTATS: Le sondage a été complété par 729 participants provenant de 73 pays différents, avec un taux de réponse de 20,1 % (729/3630) pour le nombre de courriels ouverts et de 8,5 % (729/8572) pour le nombre de courriels envoyés. La plupart des répondants (87,7 %) se sont identifiés comme anesthésiologistes (académique ou consultant) et pratiquaient l'anesthésie obstétricale et non obstétricale (55,3 %). Leur pratique de l'anesthésie régionale s'est étendue ou est demeurée inchangée, et seulement 2 % des répondants ont indiqué avoir diminué leur utilisation de cette pratique par rapport à la période pré-pandémique. Les principales raisons d'une augmentation de l'utilisation de l'anesthésie régionale étaient de réduire la nécessité d'une intervention médicale générant des aérosols et de réduire le risque de complications potentielles pour les patients. La raison la plus courante de diminution du recours à l'anesthésie régionale était le risque de conversion urgente à une anesthésie générale. Environ 70 % des intervenants ont utilisé des précautions en matière de propagation des aérosols lorsqu'ils procuraient des soins à un patient sous anesthésie régionale. La méthode d'administration d'oxygène la plus fréquemment utilisée était les canules nasales avec un masque chirurgical superposé (61 %). CONCLUSION: Compte tenu des avantages perçus de l'anesthésie régionale par rapport à l'anesthésie générale, environ la moitié des membres de trois sociétés d'anesthésie régionale semblent avoir élargi leur utilisation des techniques d'anesthésie régionale pendant la vague initiale de la pandémie de COVID-19.

Factors associated with rebound pain after peripheral nerve block for ambulatory surgery.

BACKGROUND: Rebound pain is a common, yet under-recognised acute increase in pain severity after a peripheral nerve block (PNB) has receded, typically manifesting within 24 h after the block was performed. This retrospective cohort study investigated the incidence and factors associated with rebound pain in patients who received a PNB for ambulatory surgery. METHODS: Ambulatory surgery patients who received a preoperative PNB between March 2017 and February 2019 were included. Rebound pain was defined as the transition from well-controlled pain (numerical rating scale [NRS] ≤3) while the block is working to severe pain (NRS ≥7) within 24 h of block performance. Patient, surgical, and anaesthetic factors were analysed for association with rebound pain by univariate, multivariable, and machine learning methods. RESULTS: Four hundred and eighty-two (49.6%) of 972 included patients experienced rebound pain as per the definition. Multivariable analysis showed that the factors independently associated with rebound pain were younger age (odds ratio [OR] 0.98; 95% confidence interval [CI] 0.97-0.99), female gender (OR 1.52 [1.15-2.02]), surgery involving bone (OR 1.82 [1.38-2.40]), and absence of perioperative i.v. dexamethasone (OR 1.78 [1.12-2.83]). Despite a high incidence of rebound pain, there were high rates of patient satisfaction (83.2%) and return to daily activities (96.5%). CONCLUSIONS: Rebound pain occurred in half of the patients and showed independent associations with age, female gender, bone surgery, and absence of intraoperative use of i.v. dexamethasone. Until further research is available, clinicians should continue to use preventative strategies, especially for patients at higher risk of experiencing rebound pain.

Critical structures in the needle path of the costoclavicular brachial plexus block: a cadaver study.

PURPOSE: The costoclavicular block is a relatively novel alternative to the infraclavicular block. We aimed to determine the anatomical structures vulnerable to needle injury during a costoclavicular block. METHODS: The needle path consistent with a costoclavicular block approach was performed bilaterally on four lightly embalmed cadavers using ultrasound guidance. Careful dissection was performed with 18-G Tuohy needles in situ and photographs were taken. RESULTS: The needle penetrated the deltoid in six of eight cases and the pectoralis minor in three of eight cases. The subclavius tendon or its fascia were punctured in two of eight cases. The lateral cord was in contact with the needle in six procedures and punctured in three. The posterior cord was contacted in two instances, and the medial cord in one. In a single dissection, the needle was in contact with the medial antebrachial cutaneous nerve. The needle was close to the medial brachial cutaneous nerve in one case and close to the pectoral nerves in two of eight cases. While the cephalic vein and thoracoacromial artery were consistently nearby, there were no cases of vascular puncture. CONCLUSION: We found that the needle path may be close to the medial antebrachial cutaneous nerve, medial brachial cutaneous nerve, and pectoral nerves but did not traverse any critical structures aside from the lateral cord. This suggests relative safety when compared with other approaches to the infraclavicular brachial plexus. Structures dans la trajectoire de l'aiguille du bloc de plexus brachial costoclaviculaire : une étude cadavérique.

RéSUMé: OBJECTIF: Le bloc costoclaviculaire est une alternative relativement nouvelle au bloc infraclaviculaire. Notre objectif était de déterminer quelles structures anatomiques étaient vulnérables aux lésions provoquées par l'aiguille pendant un bloc costoclaviculaire MéTHODE: Nous avons simulé, sous échoguidage, une trajectoire d'aiguille correspondant à l'approche pour un bloc costoclaviculaire en bilatéral sur quatre cadavres légèrement embaumés. Une dissection minutieuse a ensuite été exécutée avec des aiguilles Tuohy 18-G laissées in situ et des photographies ont été prises. RéSULTATS: L'aiguille a pénétré le deltoïde dans six des huit cas et le muscle petit pectoral dans trois des huit cas. Le tendon sous-clavier ou son fascia ont été perforés dans deux des huit cas. Le cordon latéral a été en contact avec l'aiguille dans six interventions et perforé dans trois cas. Le cordon postérieur a été touché dans deux cas, et le cordon médial dans un cas. L'aiguille a touché le nerf cutané antébrachial médial dans une seule dissection. L'aiguille était proche du nerf cutané brachial médial dans un cas et proche des nerfs pectoraux dans deux des huit cas. Alors que la veine céphalique et l'artère thoraco-acromiale étaient toujours à proximité, il n'y a eu aucun cas de ponction vasculaire. CONCLUSION: Nous avons constaté que la trajectoire de l'aiguille peut être à proximité du nerf cutané antébrachial médial, du nerf cutané brachial médial et du nerf pectoral, mais l'aiguille n'a pas traversé de structures critiques hormis le cordon latéral. Ceci suggère l'innocuité relative de ce type de bloc par rapport à d'autres approches du plexus brachial infraclaviculaire.

Effect of combining peri-hamstring injection or anterior obturator nerve block on the analgesic efficacy of adductor canal block for anterior cruciate ligament reconstruction: a randomised controlled trial.

BACKGROUND: Pain after anterior cruciate ligament reconstruction (ACLR) with autologous hamstring graft can be attributed to both arthroscopic surgery and the graft donor site. This study investigated whether donor site pain control was superior with the addition of either peri-hamstring injection or anterior division obturator nerve block in comparison with adductor canal block (ACB) alone. METHODS: Patients scheduled to undergo knee arthroscopy with ACLR using a graft from the ipsilateral hamstring were randomised to one of three groups. All patients received ACB and multimodal analgesia. Subjects in Group H received peri-hamstring local anaesthetic injection while subjects in Group O received an anterior division of the obturator nerve block, and subjects in Group C served as a control group (ACB alone). RESULTS: In 105 subjects undergoing ACLR, there was no significant difference between groups H, O, and C for the primary outcome of pain on movement as assessed by numerical rating scale (NRS) on knee flexion at 2 h after operation (P=0.11). There was no difference in NRS at any time point in the first 48 h after operation, nor was there a difference in oxycodone consumption between the three groups at 24 h (P=0.2). Worst knee pain was initially at the graft donor site in all three groups, which transitioned to anterior knee pain after 12 h. CONCLUSIONS: The addition of ultrasound-guided peri-hamstring injection or anterior division of obturator nerve block to ACB did not result in a significant reduction in pain or opioid consumption after ACLR with ipsilateral hamstring graft. CLINICAL TRIAL REGISTRATION: NCT01868282.

Factors Associated With Failure of Spinal Anesthetic: An 8-Year Retrospective Analysis of Patients Undergoing Elective Hip and Knee Joint Arthroplasty.

The primary outcome of this 8-year retrospective review was the failure of spinal anesthetic (SA) in elective hip and knee joint arthroplasty surgery. Of 3542 SAs, a total of 135 failures were identified (3.8%). Factors associated with increased odds of failure were younger age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.01-1.05), lower body mass index (BMI; OR, 1.04 [1.01-1.08]), hip arthroplasty (OR, 1.90 [1.28-2.84]) compared to knee arthroplasty, needle insertion at L4-5 (OR, 4.61 [2.02-10.54]) and L5-S1 (OR, 7.66 [2.47-23.7]) compared to L2-3, 22-gauge needle size (OR, 2.17 [1.34-3.52]) compared to 25-gauge needle, and hyperbaric bupivacaine (OR, 1.66 [1.09-2.53]) compared to isobaric bupivacaine.

Efficacy of Intrathecal Fentanyl for Cesarean Delivery: A Systematic Review and Meta-analysis of Randomized Controlled Trials With Trial Sequential Analysis.

BACKGROUND: Fentanyl and morphine are the 2 most commonly added opioids to bupivacaine for spinal anesthesia during cesarean delivery. Numerous clinical trials have assessed efficacy and safety of different doses of fentanyl added to intrathecal bupivacaine for spinal anesthesia, yet its benefit, harm, and optimal dose remain unclear. This study aimed to systematically review the evidence of the efficacy of fentanyl when added to intrathecal bupivacaine alone and when added to bupivacaine with morphine for spinal anesthesia during cesarean delivery. METHODS: Key electronic databases (PubMed, Embase, and Cochrane Library) were searched for randomized controlled trials in the cesarean delivery population. The primary outcome was the failure rate of spinal anesthesia, as assessed by the need for either conversion to general anesthesia or intraoperative analgesic supplementation. Two reviewers independently extracted the data using a standardized electronic form. Results are expressed as relative risks or mean differences with 95% CIs. RESULTS: Seventeen randomized controlled clinical trials (most judged as low or unclear risk of bias) with 1064 participants provided data for the meta-analysis. Fentanyl added to intrathecal bupivacaine alone reduced the need for intraoperative supplemental analgesia (relative risk, 0.18; 95% CI, 0.11-0.27; number needed to treat, 4) and the incidence of nausea/vomiting (relative risk, 0.41; 95% CI, 0.24-0.70; number needed to treat, 6.5), with longer time to first postoperative analgesia request (mean difference, 91 minutes; 95% CI, 69-113). No difference was observed regarding the need for conversion to general anesthesia (relative risk, 0.67; 95% CI, 0.12-3.57), the incidence of hypotension, the onset of sensory block, or the duration of motor block. However, the addition of intrathecal fentanyl was associated with higher incidence of intraoperative pruritus (relative risk, 5.89; 95% CI, 2.07-16.79; number needed to harm, 13.5). The inclusion of fentanyl to intrathecal bupivacaine-morphine compared to intrathecal bupivacaine-morphine alone conferred a similar benefit, with a significantly reduced need for intraoperative supplemental analgesia (relative risk, 0.16; 95% CI, 0.03-0.95; number needed to treat, 9). Analysis using a funnel plot indicated a possibility of publication bias in included studies. CONCLUSIONS: Current evidence suggests a benefit of using fentanyl as both an additive to intrathecal bupivacaine alone and to intrathecal bupivacaine combined with morphine for cesarean delivery under spinal anesthesia. The possibility of publication bias, small sample size, and high risk of bias in some of the included studies warrant treating the results with caution.

Quadratus lumborum block for postoperative analgesia: a systematic review and meta-analysis.

PURPOSE: The goal of the present systematic review is to determine the efficacy of the quadratus lumborum block (QLB) in providing postoperative analgesia for abdominal wall and hip surgeries when compared with placebo or other analgesic techniques. METHODS: Electronic databases (Medline, Embase, Cochrane Central, and Scopus) were searched for keywords and controlled vocabulary terms related to QLB from their inception to November 2019. The included studies compared ultrasound-guided single-injection QLB to placebo and other analgesic techniques in adult patients. RESULTS: Forty-two randomized-controlled trials provided the data for this systematic review. Eight studies were assessed as high risk of bias in at least one domain. The included studies had significant heterogeneity with regard to the type of surgery, comparator groups, and outcomes measured; therefore, a limited quantitative analysis was undertaken for the comparison of QLB vs no block or placebo in patients undergoing Cesarean delivery only. For Cesarean delivery, the QLB reduced the opioid use by 24.1 (95% confidence interval, 17.3 to 30.9) mg oral morphine equivalents in the first postoperative 24 hr compared with no block or placebo with no difference in pain scores at rest. For other surgical procedures, the pain scores and opioid use were lower in the QLB group when compared with placebo or no regional anesthesia technique. When compared with other regional anesthetic techniques, the analgesic benefit of QLB was marginal. CONCLUSION: Quadratus lumborum block provided analgesic benefits compared with placebo for use in the abdominal wall and hip surgery, with only marginal benefits compared with other regional analgesic techniques. The identified studies used different variants of QLB in many different surgery types. These findings and conclusions, therefore, should be considered preliminary. TRIAL REGISTRATION: PROSPERO (CRD42018095965); registered 6 June 2018.

RéSUMé: OBJECTIF: L'objectif de cette revue systématique était de déterminer l'efficacité d'un bloc du muscle du carré des lombes pour l'analgésie postopératoire après une chirurgie impliquant la paroi abdominale ou les hanches, comparativement à un placebo ou à d'autres techniques analgésiques. MéTHODE: Nous avons réalisé des recherches dans les bases de données électroniques (Medline, Embase, Cochrane Central, et Scopus) pour trouver les mots-clés et les termes de vocabulaire contrôlé liés au bloc du carré des lombes depuis la création des bases de données jusqu'au mois de novembre 2019. Les études incluses comparaient une injection échoguidée unique pour réaliser un bloc du carré des lombes à un placebo et à d'autres techniques analgésiques chez des patients adultes. RéSULTATS: Quarante-deux études randomisées contrôlées ont fourni des données pour cette revue systématique. Huit études démontraient un risque élevé de biais dans au moins un domaine. Les études incluses présentaient une hétérogénéité importante en matière de type de chirurgie, de groupes comparés, et de résultats mesurés; une analyse quantitative limitée a par conséquent été entreprise pour comparer l'utilisation d'un bloc du muscle carré des lombes vs aucun bloc ou un placebo chez des patientes subissant un accouchement par césarienne. Lors d'un accouchement par césarienne, le bloc du carré des lombes a réduit la consommation d'opioïdes de 24,1 (intervalle de confiance 95 %, 17,3 à 30,9) mg en équivalent de morphine orale au cours des premières 24 h postopératoires par rapport à un accouchement par césarienne sans bloc ou avec placebo, et aucune différence n'a été observée dans les scores de douleur au repos. En ce qui a trait aux autres interventions chirurgicales, les scores de douleur et la consommation d'opioïdes étaient plus bas dans le groupe bloc du carré des lombes par rapport aux groupes placebo / aucune technique d'anesthésie régionale. Comparativement à d'autres techniques d'anesthésie régionale, les bienfaits analgésiques d'un bloc du carré des lombes étaient marginaux. CONCLUSION: Le bloc du carré des lombes a procuré des bienfaits analgésiques par rapport à un placebo lorsqu'il était utilisé en cas de chirurgie impliquant la paroi abdominale ou la hanche, mais ses bienfaits étaient marginaux comparativement aux autres techniques d'analgésie régionale. Les études identifiées utilisaient différentes variantes du bloc du carré des lombes dans de nombreux types différents de chirurgie. Il convient donc de considérer comme préliminaires ces observations et conclusions. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42018095965); enregistrée le 6 juin 2018.

Wrong-site nerve blocks: evidence-review and prevention strategies.

PURPOSE OF REVIEW: There has been increasing attention to wrong site medical procedures over the last 20 years. This review aims to provide a summary of the current understanding and recommendations for the prevention of wrong-site nerve blocks (WSNB). RECENT FINDINGS: Various procedural, patient, practitioner, and organizational factors have been associated with the risk of WSNB. Recent findings have suggested that the use of a checklist is likely to reduce the incidence of WSNB. However, despite the widespread use of preprocedural checklists, WSNB continue to occur at significant frequency. This may be due to the inability of practitioners and teams to implement checklists correctly or the cognitive errors that prevent checklists from being executed as designed. SUMMARY: Though the evidence is limited, it is recommended that a combination of multiple strategies should be employed to prevent WSNB. These include the use of preprocedural markings, well constructed checklists, time-out/stop-moments, and cognitive/physical aids. Effective implementation requires team education and engagement that empowers all team members to speak up as part of a culture of safety.