Standing out or fitting in: A latent projective content analysis of discrimination of women and 2SLGBTQ+ anesthesiologists and providers.

INTRODUCTION: Discrimination toward sex and gender minority anesthesiologists and anesthesia trainees exists. Potential reasons for this discrimination are unclear and incompletely characterized. This study sought to better understand what discrimination looks like for sex and gender minorities in anesthesiology and the culture within anesthesiology that allows this discrimination to occur. MATERIALS AND METHODS: With institutional research ethics board approval and informed consent, we performed a qualitative analysis of free-text responses from a previously-published internet-based cross-sectional survey distributed to Canadian anesthesiology residents, fellows, and staff. The purpose of this survey was to characterize intersections between respondent gender or sexuality with experiences of discrimination in the workplace. Separate analysis of qualitative and quantitative components of this survey was planned a priori, and the quantitative component was published elsewhere. Free-text responses were independently coded by two researchers and subsequently synthesized into emerging themes using latent projective content analysis sensitized by Butler's theory of performativity. RESULTS: Out of 490 free-text responses from 171 respondents [140 (81.9%) identifying as heterosexual], two themes emerged: i) fitting in: performativity reinforcing the status quo, and ii) standing out: performativity as a means of disruptive social change. Power structures were observed to favour individuals who "fit in" with the normative performances of gender and/or sexuality. DISCUSSION: Our study illuminates how individuals whose performances of gender and sexuality "fit in" with those expected normative performances reinforce a workplace culture that advantages them, whereas individuals whose performances of gender and sexuality "stand out" disproportionately experience discrimination. The dismantling of bias and discrimination in the anesthesiology workplace requires individuals (a) who are empowered within their workplace because they "fit in" with the majority; (b) who recognize discrimination toward communities of their peers and/or colleagues; and (c) who actively choose to "stand out".

The analgesic efficacy of transversus abdominis plane block vs. wound infiltration after inguinal and infra-umbilical hernia repairs: A systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Both transversus abdominis plane (TAP) block and wound infiltration with local anaesthetic have been used to relieve pain after inguinal or infra-umbilical hernia repair. OBJECTIVES: To determine whether TAP block or local anaesthetic infiltration is the best analgesic option after inguinal or infra-umbilical hernia repair. DESIGN: Systematic review and meta-analysis with trial sequential analysis. DATA SOURCES: MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science, up to June, 2020. ELIGIBILITY CRITERIA: We retrieved randomised controlled trials comparing TAP block with wound infiltration after inguinal or infra-umbilical hernia repair. Primary outcome was rest pain score (analogue scale 0 to 10) at 2 postoperative hours. Secondary pain-related outcomes included rest pain score at 12 and 24 h, and intravenous morphine consumption at 2, 12 and 24 h. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, haematoma, visceral injury and systemic toxicity of local anaesthetic. RESULTS: Seven trials including 420 patients were identified. There was a significant difference in rest pain score at 2 postoperative hours in favour of TAP block compared with wound infiltration, with a mean (95% confidence interval) difference of -0.8 (-1.3 to -0.2); I2  = 85%; P   =  0.01. Most secondary pain-related outcomes were also significantly improved following TAP block. No complication was reported. The overall quality of evidence was moderate. CONCLUSION: There is moderate level evidence that TAP block provides superior analgesia compared with wound infiltration following inguinal or infra-umbilical hernia repair. TRIAL REGISTRY NUMBER: PROSPERO CRD42020208053.

The Analgesic Efficacy of Transversus Abdominis Plane Block After Bariatric Surgery: a Systematic Review and Meta-analysis with Trial Sequential Analysis.

The transversus abdominis plane (TAP) block has been used to relieve pain after bariatric surgery but with conflicting data on its analgesic efficacy. We conducted this systematic review and meta-analysis with trial sequential analysis to clarify whether TAP block provides effective postoperative analgesia in patients undergoing bariatric surgery. We systematically searched the literature for any trials comparing TAP block with a control group (no block or sham injection). The primary outcome was pain scores at rest (analog scale, 0-10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores at rest at 12 and 24 h and both dynamic pain scores and intravenous morphine equivalent consumption at 2, 12 and 24 h. Additional secondary outcomes sought were rates of postoperative infection, haematoma, visceral injury and local anaesthetic systemic toxicity. Thirteen trials totalling 1025 patients were identified. Pain scores at rest at 2 postoperative hours were significantly lower in the TAP block group compared with the control group, with a mean (95% CI) difference of - 1.8 (- 2.5, - 1.1); I2 = 85%; p < 0.00001. All other secondary pain-related outcomes were also significantly lower in the intervention group with the exception of dynamic pain scores and intravenous morphine equivalent consumption at 2 postoperative hours. Rates of block-related complications were not significantly different between groups. The overall quality of evidence was moderate-to-low. There is moderate-to-low level evidence that the TAP block improves postoperative analgesia after bariatric surgery up to 24 postoperative hours, when compared with a control group, without major reported complications. Clinical Trial NumberPROSPERO - registration number: CRD42019136542.

De-implementing wisely: developing the evidence base to reduce low-value care.

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

Low- versus high-dose intraoperative opioids: A systematic review with meta-analyses and trial sequential analyses.

BACKGROUND: Opioid-induced hyperalgesia is a state of nociceptive sensitisation secondary to opioid administration. The objective of this meta-analysis was to test the hypothesis that high-dose intraoperative opioids contribute to increased post-operative pain and hyperalgesia when compared with a low-dose regimen in patients under general anaesthesia. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and rated the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation system. Only trials investigating pain outcomes and comparing two different dosages of the same intraoperative opioid in patients under general anaesthesia were included. The primary outcome was pain score (analogue scale, 0-10) at 24 post-operative hours. Secondary outcomes included pain score and cumulative intravenous morphine equivalents (mg) consumed at 2 post-operative hours, together with mechanical pain threshold (g·mm-2 ). RESULTS: Twenty-seven randomised controlled trials, including 1630 patients, were identified. Pain score at rest at 24 post-operative hours was increased in the high-dose group (mean difference [95% CI]: -0.2 [-0.4, -0.1]; trial sequential analysis-adjusted CI: -0.4, -0.02; low certainty of evidence). Similarly, at 2 post-operative hours, both pain score (mean difference [95% CI]: -0.4 [-0.6, -0.2]; low certainty of evidence) and cumulative intravenous morphine equivalents consumed (mean difference [95% CI]: -1.6 mg [-2.6, -0.7]; low certainty of evidence) were significantly higher in the high-dose group. Finally, the threshold for mechanical pain was significantly lower in the high-dose group (mean difference to pressure [95% CI]: 3.8 g·mm-2 [1.8, 5.8]; low certainty of evidence). CONCLUSIONS: There is low certainty of evidence that high-dose intraoperative opioid administration increases pain scores in the post-operative period, when compared with a low-dose regimen.

Adductor canal block versus local infiltration analgesia for postoperative pain after anterior cruciate ligament reconstruction: a single centre randomised controlled triple-blinded trial.

BACKGROUND: Both the adductor canal block (ACB) and local infiltration analgesia (LIA) are effective analgesic techniques after anterior cruciate ligament (ACL) reconstruction, but they have never been compared head-to-head. This randomised controlled triple-blinded trial tested the hypothesis that ACB provides superior analgesia to LIA after ACL reconstruction, with additional focus on postoperative functional outcomes. METHODS: Of 104 enrolled ACL reconstruction patients receiving general anaesthesia, 52 were randomly allocated to either ACB under ultrasound guidance or LIA. For each intervention, ropivacaine 0.5%, 20 ml was injected. Postoperative pain treatment followed a predefined protocol with i.v. patient-controlled morphine, paracetamol, and ibuprofen. The primary outcome was cumulative i.v. morphine consumption at 24 h after operation. Secondary pain-related outcomes included resting and dynamic pain scores (numeric rating scale out of 10) measured 2, 24, and 48 h after operation and cumulative i.v. morphine consumption 2 and 48 h after operation. Early function-related outcomes evaluated were quadriceps strength, walking distance, and range of motion, all measured 24 and 48 h after operation. Late function-related outcomes were concentric quadriceps strength, single-hop test, triple-hop test, cross-over test, and Y balance test, measured at 4 and 8 postoperative months. RESULTS: Cumulative i.v. morphine consumption at 24 h was similar between groups (ACB group: 17.1 mg [95% confidence interval, CI: 13.1, 21.2]; LIA group: 17.7 mg [95% CI: 13.2, 22.6], P=0.84). Similarly, no differences between groups were seen in the secondary pain- or function-related outcomes. CONCLUSIONS: ACB and LIA result in equivalent postoperative opioid consumption with similar impact on postoperative pain scores and functional outcomes. CLINICAL TRIAL REGISTRATION: NCT02524652.

Preoperative Laboratory Investigations: Rates and Variability Prior to Low-risk Surgical Procedures.

BACKGROUND: Increasing attention has been focused on low-value healthcare services. Through Choosing Wisely campaigns, routine laboratory testing before low-risk surgery has been discouraged in the absence of clinical indications. The authors investigated rates, determinants, and institutional variation in laboratory testing before low-risk procedures. METHODS: Patients who underwent ophthalmologic surgeries or predefined low-risk surgeries in Ontario, Canada, between April 1, 2008, and March 31, 2013, were identified from population-based administrative databases. Preoperative blood work was defined as a complete blood count, prothrombin time, partial thromboplastin, or basic metabolic panel within 60 days before an index procedure. Adjusted associations between patient and institutional factors and preoperative testing were assessed with hierarchical multivariable logistic regression. Institutional variation was characterized using the median odds ratio. RESULTS: The cohort included 906,902 patients who underwent 1,330,466 procedures (57.1% ophthalmologic and 42.9% low-risk surgery) at 119 institutions. Preoperative blood work preceded 400,058 (30.1%) procedures. The unadjusted institutional rate of preoperative blood work varied widely (0.0 to 98.1%). In regression modeling, significant predictors of preoperative testing included atrial fibrillation (adjusted odds ratio [AOR], 2.58; 95% CI, 2.51 to 2.66), preoperative medical consultation (AOR, 1.68; 95% CI, 1.65 to 1.71), previous mitral valve replacement (AOR, 2.33; 95% CI, 2.10 to 2.58), and liver disease (AOR, 1.69; 95% CI, 1.55 to 1.84). The median odds ratio for interinstitutional variation was 2.43. CONCLUSIONS: Results of this study suggest that testing is associated with a range of clinical covariates. However, an association was similarly identified with preoperative consultation, and significant variation between institutions exists across the jurisdiction.

The Analgesic Efficacy of Ultrasound-Guided Transversus Abdominis Plane Block in Adult Patients: A Meta-Analysis.

BACKGROUND: Previous meta-analyses of the transversus abdominis plane (TAP) block have examined a maximum of 12 articles, including fewer than 650 participants, and have not examined the effect of ultrasound-guided techniques specifically. Recently, many trials that use ultrasound approaches to TAP block have been published, which report conflicting analgesic results. This meta-analysis aims to evaluate the analgesic efficacy of ultrasound-guided TAP blocks exclusively for all types of abdominal surgeries in adult patients. METHODS: This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The primary outcome was cumulative IV morphine consumption at 6 hours postoperatively, analyzed according to the type of surgery, the type of surgical anesthesia, the timing of injection, the block approach adopted, and the presence of postoperative multimodal analgesia. Secondary outcomes included IV morphine consumption at 24 hours postoperatively; pain scores at rest and on movement at 6 and 24 hours postoperatively; and postoperative nausea and vomiting, pruritus, and rates of complications. RESULTS: Thirty-one controlled trials including 1611 adult participants were identified. Independent of the type of surgery (abdominal laparotomy, abdominal laparoscopy, and cesarean delivery) but not independent of the type of surgical anesthesia (general anesthesia, spinal anesthesia with or without intrathecal long-acting opioid), ultrasound-guided TAP block reduced IV morphine consumption at 6 hours postoperatively by a mean difference of 6 mg (95% confidence interval [CI], -7 to -4 mg; I2 = 94%; P < 0.00001). The magnitude of the reduction in morphine consumption at 6 hours postoperatively was not influenced by the timing of injection (I2 = 0%; P = 0.72), the block approach adopted (I2 = 0%; P = 0.72), or the presence of postoperative multimodal analgesia (I2 = 73%; P = 0.05). This difference persisted at 24 hours postoperatively (mean difference, -11 mg; 95% CI, -14 to -8 mg; I2 = 99%; P < 0.00001). Pain scores at rest and on movement were reduced at 6 hours postoperatively (mean difference at rest, -10; 95% CI, -15 to -5; I2 = 92%; P = 0.0002; mean difference on movement, -9; 95% CI, -14 to -5; I2 = 58%; P < 0.00001). There were neither differences in the incidence of postoperative nausea and vomiting (I2 = 1%; P = 0.59) nor in the pruritus (I2 = 12%; P = 0.58) Two minor complications (1 bruise and 1 anaphylactoid reaction) were reported in 1028 patients. CONCLUSIONS: Ultrasound-guided TAP block provides marginal postoperative analgesic efficacy after abdominal laparotomy or laparoscopy and cesarean delivery. However, it does not provide additional analgesic effect in patients who also received spinal anesthesia containing a long-acting opioid. The minimal analgesic efficacy is independent of the timing of injection, the approach adopted, or the presence of postoperative multimodal analgesia. Because of heterogeneity of the results, these findings should be interpreted with caution.

Preoperative testing before low-risk surgical procedures.

BACKGROUND: There is concern about increasing utilization of low-value health care services, including preoperative testing for low-risk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures. METHODS: For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure. RESULTS: Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%-31.1%) and 10.8% (95% CI 10.8%-10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%-2.9%) and 2.1% (95% CI 2.1%-2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66-75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6-19.0; for radiography, adjusted OR 2.9, 95% CI 2.8-3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5-8.8; for radiography, adjusted OR 2.2, 95% CI 2.1-2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7-6.9; for radiography, adjusted OR 3.6, 95% CI 3.5-3.6). The median ORs for receipt of preoperative ECG and radiography were 2.3 and 1.6, respectively. INTERPRETATION: Despite guideline recommendations to limit testing before low-risk surgical procedures, preoperative ECG and chest radiography were performed frequently. Significant variation across institutions remained after adjustment for patient- and institution-level factors.

The impact of analgesic modality on early ambulation following total knee arthroplasty.

INTRODUCTION: Total knee arthroplasty is associated with moderate to severe pain, and effective analgesia is essential to facilitate postoperative recovery. This retrospective cohort study examined the analgesic and rehabilitation outcomes associated with 48-hour continuous femoral nerve block, local infiltration analgesia, or local infiltration analgesia plus adductor canal nerve block. METHODS: Patients undergoing total knee arthroplasty under spinal anesthesia, during an 8-month period, were retrospectively assessed with a targeted review of 100 patients per group. Records of eligible patients were reviewed to identify the analgesic technique used and the primary outcome of distance walked on postoperative day 1. Secondary outcomes included ambulation on days 2 and 3, numeric rating scale pain scores, opioid consumption, and adverse effects and discharge disposition. RESULTS: Two hundred ninety-eight eligible patients were reviewed. Local infiltration analgesia and local infiltration plus adductor canal block were associated with longer distances walked on postoperative day 1 than continuous femoral nerve block (median values of 20, 30, and 0 m, respectively; P < 0.0001). The addition of adductor canal block was associated with further improvement in early ambulation benchmarks and a higher rate of home discharge compared with only local infiltration (88.2% vs 73.2%, P = 0.018). Local infiltration with or without adductor canal block was associated with lower pain scores at rest and during movement for the first 24 hours and lower opioid consumption than continuous femoral nerve infusion. CONCLUSIONS: Local infiltration analgesia was associated with improved early analgesia and ambulation. The addition of adductor canal nerve block was associated with further improvements in early ambulation and a higher incidence of home discharge.

Ultrasound-guided transversus abdominis plane (TAP) block for laparoscopic gastric-bypass surgery: a prospective randomized controlled double-blinded trial.

BACKGROUND: Despite the laparoscopic approach, patients can suffer moderate to severe pain following bariatric surgery. This randomized controlled double-blinded trial investigated the analgesic efficacy of ultrasound-guided transversus abdominis plane (TAP) blocks for laparoscopic gastric-bypass surgery. METHODS: Seventy patients undergoing laparoscopic gastric-bypass surgery were randomized to receive either bilateral ultrasound-guided subcostal TAP block injections after induction of general anesthesia or none. All patients received trocar insertion site local anesthetic infiltration and systemic analgesia. The primary outcome was cumulative opioid consumption (IV morphine equivalent) during the first 24 h postoperatively. Interval opioid consumption, pain severity scores, rates of nausea or vomiting, and rates of pruritus were measured during phase I recovery, and at 24 and 48 h postoperatively. RESULTS: There was no difference in cumulative opioid consumption during the first 24 h postoperatively between the TAP (32.2 mg [95% CI, 27.6-36.7]) and control (35.6 mg [95% CI, 28.6-42.5]; P = 0.41) groups. Postoperative opioid consumptions during phase I recovery and the 24-48-h interval were similar between groups, as were pain scores at rest and with movement during all measured intervals. The rates of nausea or vomiting and pruritus were equivalent. CONCLUSIONS: Bilateral TAP blocks do not provide additional analgesic benefit when added to trocar insertion site local anesthetic infiltration and systemic analgesia for laparoscopic gastric-bypass surgery.

Gabapentin reduces preoperative anxiety and pain catastrophizing in highly anxious patients prior to major surgery: a blinded randomized placebo-controlled trial.

INTRODUCTION: Gabapentin is increasingly being used for the treatment of postoperative pain and a variety of psychiatric diseases, including chronic anxiety disorders. Trials have reported mixed results when gabapentin has been administered for the treatment of preoperative anxiety. We tested the hypothesis that gabapentin 1,200 mg vs placebo would reduce preoperative anxiety in patients who exhibit moderate to high preoperative anxiety. METHODS: A blinded randomized controlled trial was conducted from September 2009 to June 2011 at the Toronto General Hospital. Following ethics approval and informed consent, 50 female patients with a 0-10 numeric rating scale (NRS) anxiety score of greater than or equal to 5/10 consented to receive either gabapentin 1,200 mg (n = 25) or placebo (n = 25) prior to surgery. Randomization was computer generated, and the Investigational Pharmacy was responsible for the blinding and dispensing of medication. All patients and care providers, including physicians, nurses, and study personnel, were blinded to group allocation. Before administering the study medication, baseline anxiety levels were measured using a NRS, the Spielberger State-Trait Anxiety Inventories, the Pain Catastrophizing Scale, and the Pain Anxiety Symptoms Scale-20. Baseline pain intensity (0-10 NRS) and level of sedation (0-10 NRS and Richmond Agitation-Sedation Scale [RASS]) were also measured. Two hours after the administration of gabapentin or placebo (prior to surgery), patients again rated their anxiety, pain, and sedation levels using the same measurement tools as at baseline. The main outcome was a reduction in preoperative anxiety. RESULTS: Forty-four patients (22 treated with gabapentin 1,200 mg and 22 treated with placebo) were included in the analysis of the primary outcome. Analysis of covariance in which pre-drug NRS anxiety scores were used as the covariate showed that post-drug preoperative NRS anxiety (Effect size, 1.44; confidence interval [CI] 0.19 to 2.70) and pain catastrophizing (Effect size, 0.43; CI 0.12 to 0.74) scores were significantly lower in the gabapentin group than in the placebo control group, respectively. Post-drug sedation (Effect size, -3.02; CI -4.28 to -1.77) and RASS (Effect size, 0.41; CI 0.12 to 0.71) scores were significantly higher in the gabapentin group than in the placebo group, respectively. CONCLUSIONS: Administration of gabapentin 1,200 mg prior to surgery reduces preoperative NRS anxiety scores and pain catastrophizing scores and increases sedation prior to entering the operating room. These results suggest that gabapentin 1,200 mg may be a treatment option for patients who exhibit high levels of preoperative anxiety and pain catastrophizing; however, the sedative properties of the medication and the possibility of delayed postoperative discharge in the elective ambulatory population need to be considered.