Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

BACKGROUND: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS: A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS: Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial.

BACKGROUND: The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS: A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS: A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS: Long-term outcomes were similar with spinal versus general anesthesia.

The evolution and formalization of anesthesia assistant roles across Canada.

PURPOSE: The purpose of this Special Article is to document the evolution of the anesthesia assistant (AA) profession in Canada and summarize AA practice at Canadian institutions as it exists today, five decades after Quebec and 15 years after most other provinces formalized AA practice. SOURCE: Through the Management Committee of the Association of Canadian University Departments of Anesthesia (ACUDA), we conducted a purposeful sampling of all ACUDA chairs or their delegates. We requested the following data: history of AAs becoming a reality in their particular province or region; potential recruitment pools; training programs and curricula; pathway to credentialing; funding, pay, retention, recruitment, and status of union representation; and metrics. PRINCIPAL FINDINGS: Data were provided by 19 institutions in 8 provinces: Newfoundland and Labrador, Nova Scotia, Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia. Given the different health care governance structures across the provinces, AA roles vary in terms of its associated technical, clinical, and educational responsibilities. The role of AAs in supporting anesthesia care through equipment maintenance and assistance with airway management, resuscitation, and administration of regional anesthesia seems to be well established, as is their role in providing brief intraoperative relief for anesthesiologists during a stable period of anesthesia. Anesthesia assistant duties continue to evolve, becoming more aligned with the specific institution and less dependent on the supervising anesthesiologist. Apart from the initial metrics collected during the Ontario ACT implementation pilot projects, we are not aware of any formal metrics, current or ongoing, being collected across Canada, related to either patient safety events or perioperative efficiency. CONCLUSIONS: This compilation of pan-Canadian AA data shows diverse models of practice and highlights the value to patients and the health care system as a whole of incorporating these allied professionals into the anesthesia care team (ACT). The present findings allow us to offer suggestions for consideration during discussions of retention, recruitment, program expansion, and cross-country collection of metrics and other data. We conclude by making six recommendations: 1. recognize that implementation of ACTs is a key element in solving the challenge of an increasing surgical backlog; 2. develop, or facilitate the development of, metrics and increase data-sharing nationally to enable health care authorities to better understand the importance of AAs in patient safety and perioperative efficiency; 3. develop and implement funding strategies to lower the barriers to AA training such as hospital-sponsored positions, ongoing salary support, and return-of-service arrangements; 4. ensure that salaries appropriately reflect the increased level of training and added levels of responsibility of certified AAs; 5. develop long-term strategies to ensure stable funding, recruitment and retention, and a better match between the number of AA training positions and the need for newly certified AAs; and 6. engage all stakeholders to acknowledge that AAs, as knowledgeable and specifically trained assistants, not only fulfill their defined clinical role but also contribute significantly to patient safety and clinical efficiency by assuming nondirect patient care tasks.

RéSUMé: OBJECTIF: Le but de cet article spécial est de documenter l'évolution de la profession d'assistant·e en anesthésie (AA) au Canada et de résumer la pratique des AA dans les établissements canadiens telle qu'elle existe aujourd'hui, cinquante ans après que le Québec et quinze ans après que la plupart des autres provinces ont officialisé la pratique des AA. SOURCES: Par l'entremise du Comité de gestion de l'Association canadienne universitaire des départements d'anesthésie (ACUDA), nous avons réalisé un échantillonnage ciblé de tou·tes les président·es de l'ACUDA ou de leurs délégué·es. Nous avons demandé les données suivantes : historique de la concrétisation de la profession d'AA dans leur province ou région; bassins de recrutement potentiels; programmes de formation et programmes d'études; voie d'accès à l'accréditation; financement, rémunération, rétention, recrutement et état de la représentation syndicale; et données métriques. CONSTATATIONS PRINCIPALES: Des données ont été fournies par 19 institutions dans 8 provinces : Terre-Neuve-et-Labrador, Nouvelle-Écosse, Québec, Ontario, Manitoba, Saskatchewan, Alberta et Colombie-Britannique. Compte tenu des différentes structures de gouvernance des soins de santé dans les provinces, les rôles des AA varient en termes de responsabilités techniques, cliniques et éducatives connexes. Le rôle des AA dans le soutien des soins d'anesthésie par l'entretien du matériel et l'aide à la prise en charge des voies aériennes, à la réanimation et à l'administration de l'anesthésie régionale semble bien établi, tout comme leur rôle dans la fourniture d'un bref soulagement peropératoire aux anesthésiologistes pendant une période stable d'anesthésie. Les tâches des assistant·es en anesthésie continuent d'évoluer, devenant plus alignées sur l'établissement spécifique et moins dépendantes de l'anesthésiologiste superviseur·e. À l'exception des mesures initiales recueillies dans le cadre des projets pilotes de mise en œuvre des ESA (équipes de soins en anesthésie) en Ontario, nous ne sommes au courant d'aucune mesure officielle, actuelle ou en cours, recueillie dans l'ensemble du Canada, concernant les événements liés à la sécurité des patient·es ou à l'efficacité périopératoire. CONCLUSION: Cette compilation de données pancanadiennes sur les AA présente divers modèles de pratique et souligne l'importance pour les patient·es et le système de soins de santé dans son ensemble d'intégrer ces professionnel·les connexes à l'équipe de soins d'anesthésie (ESA). Les résultats actuels nous permettent d'avancer des suggestions à prendre en compte lors des discussions sur le maintien en poste, le recrutement, l'expansion des programmes et la collecte de mesures et d'autres données à l'échelle du pays. Nous concluons en formulant six recommandations : 1. reconnaître que la mise en œuvre des ESA constitue un élément clé pour résoudre le problème de l'augmentation de l'arriéré chirurgical; 2. élaborer ou faciliter l'élaboration de mesures et accroître le partage des données à l'échelle nationale pour permettre aux autorités sanitaires de mieux comprendre l'importance des AA pour la sécurité des patient·es et l'efficacité périopératoire; 3. élaborer et mettre en œuvre des stratégies de financement pour réduire les obstacles à la formation des AA, comme les postes parrainés par les hôpitaux, le soutien salarial continu et les ententes de retour de service; 4. veiller à ce que les salaires reflètent de manière appropriée le niveau accru de formation et les niveaux de responsabilité accrus des AA certifié·es; 5. élaborer des stratégies à long terme pour assurer un financement, un recrutement et une rétention stables, ainsi qu'une meilleure adéquation entre le nombre de postes de formation des AA et le besoin de nouveaux et nouvelles AA certifié·es; et 6. inciter toutes les personnes impliquées à reconnaître que les AA, en tant qu'assistant·es compétent·es et spécialement formé·es, non seulement remplissent leur rôle clinique défini, mais contribuent également de manière significative à la sécurité des patient·es et à l'efficacité clinique en assumant des tâches de soins non directs aux patient·es.

Comparative Effectiveness Research on Spinal versus General Anesthesia for Surgery in Older Adults.

Comparative effectiveness research aims to understand the benefits and harms of different treatments to assist patients and clinicians in making better decisions. Within anesthesia practice, comparing outcomes of spinal versus general anesthesia in older adults represents an important focus of comparative effectiveness research. The authors review methodologic issues involved in studying this topic and summarize available evidence from randomized studies in patients undergoing hip fracture surgery, elective knee and hip arthroplasty, and vascular surgery. Across contexts, randomized trials show that spinal and general anesthesia are likely to be equivalent in terms of safety and acceptability for most patients without contraindications. Choices between spinal and general anesthesia represent "preference-sensitive" care in which decisions should be guided by patients' preferences and values, informed by best available evidence.

A prospective observational study of the efficacy of ketamine for rescue analgesia in the postanesthesia recovery unit.

BACKGROUND: Early severe postoperative pain is frequently resistant to management with opioid analgesia alone. Perioperative low-dose ketamine as an analgesia adjunct has been studied extensively. Its efficacy as a rescue analgesic in the postanesthesia care unit (PACU) has not been determined. The objective of this study was to evaluate the analgesic efficacy of low-dose bolus ketamine for opioid-resistant pain in the PACU by measuring its effect on numerical rating scale (NRS) pain scores and opioid requirement. METHODS: This was a prospective observational study of adult noncardiac surgery patients with significant postoperative pain in the PACU. Patients were administered bolus doses of intravenous ketamine in 10-mg increments, repeated two to three times to an approximate maximum dose of 0.25 mg·kg-1. Primary outcomes were resting pain score reduction and opioid use from time of bolus ketamine administration to 30 min after administration of final ketamine bolus. The secondary outcome was incidence of side effects from ketamine administration. RESULTS: A convenience sample of 100 patients was chosen. The mean (standard deviation) NRS resting pain score reduction 30 min after iv ketamine administration was 2.7 (1.8) (P < 0.001). Patients with a history of previous opioid use or chronic pain were not more responsive to the effects of low-dose bolus ketamine. There were no ketamine-related adverse effects in any of the study patients. CONCLUSION: Administration of low-dose bolus ketamine in the PACU for severe opioid-resistant pain was associated with a significant improvement in analgesia in this observational study.

RéSUMé: CONTEXTE: La douleur postopératoire sévère précoce est souvent résistante à une prise en charge par analgésie opioïde seule. La kétamine périopératoire à faible dose en tant qu'analgésie adjuvante a fait l'objet d'études approfondies. Son efficacité en tant qu'analgésie de secours en salle de réveil est encore mal déterminée. L'objectif de cette étude était d'évaluer l'efficacité analgésique d'un bolus de kétamine à faible dose pour soulager la douleur résistante aux opioïdes en salle de réveil en mesurant son effet sur les scores de douleur sur une échelle d'évaluation numérique (EEN) et sur les besoins en opioïdes. MéTHODE: Il s'agissait d'une étude observationnelle prospective auprès de patients adultes ayant bénéficié d'une chirurgie non cardiaque et présentant une douleur postopératoire importante en salle de réveil. Les patients ont reçu des bolus de kétamine intraveineuse par tranches de 10 mg, répétés deux à trois fois jusqu'à une dose maximale approximative de 0,25 mg·kg−1. Les critères d'évaluation principaux étaient la réduction du score de douleur au repos et la consommation d'opioïdes à partir du moment de l'administration de kétamine en bolus jusqu'à 30 minutes après l'administration du bolus final de kétamine. Le critère d'évaluation secondaire était l'incidence d'effets secondaires liés à l'administration de kétamine. RéSULTATS: Un échantillon de commodité de 100 patients a été choisi. La réduction moyenne (écart type) du score de douleur au repos sur l'EEN 30 min après l'administration de kétamine iv était de 2,7 (1,8) (P < 0,001). Les patients ayant des antécédents de consommation antérieure d'opioïdes ou de douleur chronique n'étaient pas plus sensibles aux effets de la kétamine en bolus à faible dose. Il n'y a eu aucun effet indésirable lié à la kétamine chez aucun des patients de l'étude. CONCLUSION: L'administration de kétamine en bolus à faible dose en salle de réveil pour soulager la douleur sévère résistante aux opioïdes a été associée à une amélioration significative de l'analgésie dans cette étude observationnelle.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial.

BACKGROUND: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING: 46 U.S. and Canadian hospitals. PARTICIPANTS: Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION: Spinal or general anesthesia. MEASUREMENTS: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION: Missing outcome data and multiple outcomes assessed. CONCLUSION: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial.

INTRODUCTION: The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS: Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS: Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION: Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.

A prospective observational study of persistent opioid use after complex foot and ankle surgery.

PURPOSE: The incidence of persistent postsurgical opioid use (PPOU) after complex foot and ankle surgery is unknown. We aimed to determine the incidence and characteristics of PPOU in opioid-naïve, occasional, and regular opioid users at baseline and at six weeks, three months, and six months postoperatively. METHODS: We conducted a prospective observational study in patients undergoing complex foot and ankle surgery over an 18-month period. Daily opioid consumption was recorded at the indicated intervals. Logistic regression models were fit to predict the risk of opioid use at these intervals. The Brief Pain Inventory (BPI) was used to record pain intensity and interference. Correlations were tested between opioid use and BPI interference parameters. RESULTS: Eighty-two out of 139 consecutively approached patients were included in the final analysis. Six percent (98.3% confidence interval [CI], 2 to 20) of patients who were not using opioids preoperatively at baseline were using opioids daily at three and six months after surgery. Fifty percent (98.3% CI, 26 to 73) of patients who were regular opioid users preoperatively continued to use opioids daily six months after surgery. All associations between BPI interference parameters and opioid use were estimated to be positive. CONCLUSION: The probability of using opioid analgesia six months after complex foot and ankle surgery was significantly higher in patients who used opioids preoperatively. Regular preoperative opioid use was associated with a greater risk of PPOU compared with occasional or "as required" opioid use prior to surgery.

RéSUMé: OBJECTIF: L'incidence de consommation persistante d'opioïdes après une chirurgie (CPOC) après une chirurgie complexe du pied et de la cheville est inconnue. Notre objectif était de déterminer l'incidence et les caractéristiques de la CPOC chez les utilisateurs d'opioïdes naïfs, occasionnels et réguliers avant leur opération, puis à six semaines, trois mois et six mois après l'opération. MéTHODE: Nous avons réalisé une étude observationnelle prospective sur une période de 18 mois auprès de patients bénéficiant d'une chirurgie complexe du pied et de la cheville. La consommation quotidienne d'opioïdes a été enregistrée aux intervalles indiqués. Des modèles de régression logistique ont été utilisés pour prédire le risque de consommation d'opioïdes à ces intervalles. Le Questionnaire concis de la douleur (QCD - version française du Brief Pain Inventory, BPI) a été utilisé pour enregistrer l'intensité de la douleur et son interférence. Des corrélations ont été testées entre la consommation d'opioïdes et les paramètres d'interférence du QCD. RéSULTATS: Quatre-vingt-deux des 139 patients approchés consécutivement ont été inclus dans notre analyse finale. Six pour cent (intervalle de confiance [IC] à 98,3 %, 2 à 20) des patients qui ne consommaient pas d'opioïdes avant l'opération utilisaient des opioïdes quotidiennement trois et six mois après la chirurgie. Cinquante pour cent (IC 98,3 %, 26 à 73) des patients qui étaient des consommateurs réguliers d'opioïdes avant l'opération ont continué à utiliser des opioïdes quotidiennement six mois après la chirurgie. Toutes les associations entre les paramètres d'interférence du QCD et la consommation d'opioïdes ont été estimées positives. CONCLUSION: La probabilité d'avoir recours à une analgésie opioïde six mois après une chirurgie complexe du pied et de la cheville était significativement plus élevée chez les patients qui consommaient déjà des opioïdes avant leur opération. La consommation régulière d'opioïdes avant l'opération a été associée à un risque plus élevé de CPOC par rapport à l'utilisation occasionnelle ou « au besoin ¼ d'opioïdes avant la chirurgie.

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

PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

RéSUMé: OBJECTIF: Les chirurgies électives complexes du pied et de la cheville sont souvent associées à une douleur intense avant et après l'opération. Lorsque cette douleur est mal prise en charge, elle peut entraîner une douleur postopératoire chronique et une consommation d'opioïdes à long terme. Comme il n'existe actuellement aucune norme, nous avons cherché à élaborer des lignes directrices sur les meilleures pratiques en matière de prise en charge de la douleur. MéTHODE: Un comité directeur local (n = 16) a interrogé 116 chirurgiens nord-américains spécialistes du pied et de la cheville pour comprendre « l'état actuel ¼ de la pratique. Un groupe d'experts multidisciplinaire (n = 35) a ensuite été formé, composé de chirurgiens orthopédistes, d'anesthésiologistes, de médecins spécialistes de la douleur chronique, de médecins de soins primaires, de pharmaciens, d'infirmières autorisées, de physiothérapeutes et de psychologues cliniciens. Chaque expert a fourni jusqu'à trois recommandations de prise en charge de la douleur pour chacune des périodes suivantes : en préchirurgie, en peropératoire, pendant l'hospitalisation postopératoire et après le congé. Ces recommandations préliminaires ont été réduites, affinées et envoyées au groupe d'experts et aux répondants du sondage sur « l'état actuel ¼ afin de créer un document de consensus à l'aide d'une méthode de Delphi réalisée entre septembre et décembre 2020. RéSULTATS: Mille quatre cent cinq déclarations préliminaires ont été résumées en 51 énoncés. Un consensus fort (≥ 80 % des répondants étaient d'accord) a été atteint concernant 53 % des énoncés, notamment les suivants : le risque de consommation postopératoire d'opioïdes devrait être évalué avant l'opération; les patients naïfs aux opioïdes ne devraient pas commencer à prendre des opioïdes avant l'opération, à moins que l'analgésie multimodale non opioïde n'échoue; et si des opioïdes sont prescrits au congé, les patients devraient être informés de l'importance de réduire leur consommation d'opioïdes. Il n'y avait pas de consensus concernant le sevrage des opioïdes en période préopératoire. CONCLUSION: À l'aide d'experts multidisciplinaires et d'une méthode de Delphi, un fort consensus a été atteint dans de nombreux aspects, montrant un accord considérable malgré des données probantes limitées pour une prise en charge standardisée de la douleur chez les patients subissant une chirurgie élective complexe du pied et de la cheville. L'absence de consensus sur des questions importantes liées à la prescription et à l'interruption des opioïdes souligne la nécessité de recherches pour déterminer les pratiques exemplaires.

Perioperative pain management and chronic postsurgical pain after elective foot and ankle surgery: a scoping review.

PURPOSE: Chronic postsurgical pain (CPSP) can occur after elective mid/hindfoot and ankle surgery. Effective treatment approaches to prevent the development of CPSP in this population have not been extensively investigated. The impact of multimodal strategies to prevent CPSP following elective mid/hindfoot surgery is unknown because of both the heterogeneity of acute pain management and the lack of a recognized definition particular to this surgery. This review aimed to identify and evaluate current pain management strategies after elective mid/hindfoot and ankle surgery. SOURCES: Manual and electronic searches (MEDLINE, Embase, and Cochrane Library) were conducted of literature published between 1990 and July 2017. Comparative studies of adults undergoing elective mid/hindfoot and ankle surgery were included. Two reviewers independently reviewed studies and assessed their methodological quality. PRINCIPAL FINDINGS: We found seven randomized-controlled trials meeting our inclusion criteria. Interventions focused on regional anesthesia techniques such as continuous popliteal sciatic and femoral nerve blockade. Participants were typically followed up to 48 hr postoperatively. Only one study assessed pain six months following elective mid/hindfoot and ankle surgery. CONCLUSION: There is an overwhelming lack of evidence regarding CPSP and its management for patients undergoing elective mid/hindfoot and ankle surgery. The lack of a recognized and standard definition of CPSP after this group of surgeries precludes accurate and consistent evaluation.

RéSUMé: OBJECTIF: La douleur chronique post-chirurgicale (DCPC) peut survenir après une chirurgie non urgente de la section moyenne ou postérieure du pied, ou de la cheville. Les approches thérapeutiques efficaces pour prévenir l'apparition de DCPC dans cette population n'ont pas été examinées en profondeur. L'impact des stratégies multimodales pour prévenir la DCPC après une chirurgie non urgente de la section moyenne ou postérieure du pied est inconnu, tant en raison de l'hétérogénéité de la prise en charge de la douleur aiguë que du manque de définition reconnue spécifique à ce type de chirurgie. Ce compte-rendu a pour objectif d'identifier et d'évaluer les stratégies de prise en charge de la douleur actuellement utilisées après une chirurgie de la section moyenne ou postérieure du pied, ou de la cheville. SOURCES: Des recherches manuelles et électroniques (MEDLINE, Embase, et Librairie Cochrane) ont été menées dans la littérature publiée entre 1990 et juillet 2017. Les études comparatives portant sur des adultes subissant une chirurgie non urgente de la section moyenne ou postérieure du pied ou de la cheville ont été incluses. Deux chercheurs ont indépendamment passé en revue les études et évalué leur qualité méthodologique. CONSTATATIONS PRINCIPALES: Nous avons trouvé sept études randomisées contrôlées respectant nos critères d'inclusion. Les interventions se concentraient sur des techniques d'anesthésie régionale tels que les blocs continus des nerfs sciatiques poplités et fémoraux. Les participants bénéficiaient en général d'un suivi jusqu'à 48 h après l'opération. Une seule étude a évalué la douleur six mois après une chirurgie non urgente de la section moyenne ou postérieure du pied ou de la cheville. CONCLUSION: L'absence de données probantes est colossale en ce qui touche à la DCPC et à sa prise en charge pour les patients subissant une chirurgie non urgente de la partie moyenne ou postérieure et de la cheville. L'absence de définition normalisée et reconnue de la DCPC après ce type de chirurgie en exclut toute évaluation précise et cohérente.

Cerebral Oximetry Monitoring to Maintain Normal Cerebral Oxygen Saturation during High-risk Cardiac Surgery: A Randomized Controlled Feasibility Trial.

BACKGROUND: Cerebral oxygen desaturation during cardiac surgery has been associated with adverse perioperative outcomes. Before a large multicenter randomized controlled trial (RCT) on the impact of preventing desaturations on perioperative outcomes, the authors undertook a randomized prospective, parallel-arm, multicenter feasibility RCT to determine whether an intervention algorithm could prevent desaturations. METHODS: Eight Canadian sites randomized 201 patients between April 2012 and October 2013. The primary outcome was the success rate of reversing cerebral desaturations below 10% relative to baseline in the intervention group. Anesthesiologists were blinded to the cerebral saturation values in the control group. Intensive care unit personnel were blinded to cerebral saturation values for both groups. Secondary outcomes included the area under the curve of cerebral desaturation load, enrolment rates, and a 30-day follow-up for adverse events. RESULTS: Cerebral desaturations occurred in 71 (70%) of the 102 intervention group patients and 56 (57%) of the 99 control group patients (P = 0.04). Reversal was successful in 69 (97%) of the intervention group patients. The mean cerebral desaturation load (SD) in the operating room was smaller for intervention group patients compared with control group patients (104 [217] %.min vs. 398 [869] %.min, mean difference, -294; 95% CI, -562 to -26; P = 0.03). This was also true in the intensive care unit (P = 0.02). There were no differences in adverse events between the groups. CONCLUSIONS: Study sites were successful in reversal of desaturation, patient recruitment, randomization, and follow-up in cardiac surgery, supporting the feasibility of conducting a large multicenter RCT.

Pain management for hospitalized patients with rib fractures: A systematic review of randomized clinical trials.

STUDY OBJECTIVE: Rib fractures (RF) are common injuries. Multiple analgesia strategies are available for treatment of pain associated with RF. However, the optimal multimodal technique for pain management is not known. The primary aim of this review was to evaluate the status of evidence derived from randomized clinical trials (RCTs) on the effectiveness of pain management modalities for rib fracture pain. Other patient-centered outcomes were secondary objectives. METHODS: Searches were conducted in MEDLINE, Embase, Scopus, and Cochrane Library. The screening process involved two phases, two researchers independently screened the title and abstract and subsequently screened full text. RCT data were extracted independently by two research team members. Consensus was achieved by comparison and discussion when needed. Risk of bias assessment was performed using the Cochrane Risk of Bias 2 tool. RESULTS: A total of 1344 citations were identified. Title and abstract screening excluded 1128 citations, and full text review excluded 177 articles. A total of 32 RCTs were included in the full review. Multiple analgesia techniques and medications were identified and their effect on pain score and need for rescue opioid analgesia. None of the included studies were judged to have a high risk of bias, while only 10 studies were assessed as having a low risk of bias. CONCLUSIONS: This systematic review found that studies are of low quality with diverse methodologies and outcomes. A reduction in pain scores was found for epidural analgesia when compared with other modalities. However, the low quality of the evidence necessitates cautious interpretation of this finding. PROSPERO registration: CRD42022376298 (Nov, 16, 2022).

Is there still a place for the use of nerve stimulation?

The introduction of nerve stimulation as a method of nerve localization sparked a new beginning in regional anesthesia. It was an epochal development akin to the utilization of ultrasound in more recent times. Many experts now consider ultrasound-guided peripheral nerve blockade to be more efficient, less painful, and more successful than landmark and nerve stimulation techniques. However, inadvertent intraneural injection continues to occur despite the widespread use of ultrasound and nerve stimulation. Both of these technologies allow for only limited elucidation of needle position relative to the target nerve and are unable to reliably identify intraneural position of the needle. This article will review the role of nerve stimulation in modern regional anesthesia techniques in light of the introduction of ultrasound technology.