Preoperative triage to detect SARS-CoV-2 infection in surgical patients: lessons learned for resuming surgery.

PURPOSE: To define the impact of the COVID-19 outbreak on hospital surgical activity and assess the incidence of perioperative COVID-19 within two protocolized screening pathways for elective and non-elective surgery. METHODS: We conducted a prospective cohort study of adults undergoing surgery during the COVID-19 outbreak. The elective pathway included telephone surveys and a quantitative polymerase-chain-reaction test (RT-PCR) only for patients who were asymptomatic and at low risk of infection. Only patients with negative screening underwent surgery. In the non-elective pathway, preoperative screening was performed during the hospital admission. RESULTS: Among 835 patients considered for the elective pathway, 725 had negative RT-PCR results and underwent surgery. This reflects an 83% reduction in surgical activity from 2019. Moreover, 596 patients underwent non-elective surgery, representing a 28% reduction. Preoperatively, 39 patients (6.5%) tested positive for SARS-CoV-2 and underwent surgery through the non-elective pathway, vs. none in the elective pathway (p < 0.001). Postoperatively, 1.4% of elective surgery patients and 2.2% of non-elective surgery patients tested positive (p > 0.05). Mortality was higher in non-elective surgery (0.6% vs. 2.9%, p < 0.001) and in patients with COVID-19 (0% vs. 14%, p < 0.001). CONCLUSIONS: The low incidence of COVID-19 in elective surgeries during the outbreak demonstrates the importance and effectiveness of preoperative screening, combining surveys and RT-PCR.

Accuracy of ultrasonography predicting spread location following intraneural and subparaneural injections: a scoping review.

INTRODUCTION: Ultrasonography is useful for detecting intraneural injections. However, the reliability of the sonographic findings of intraneural and subparaneural injections in terms of true spread location and their association with intrafascicular deposits has not been systematically evaluated. EVIDENCE ACQUISITION: Our objectives were: 1) to explore the reliability of sonographic findings of intraneural and subparaneural injections when validated with tests of true spread such as histology, dissection, or imaging; and 2) to evaluate their association with intrafascicular deposits. A scoping review was conducted according to Joanna Briggs guidelines. Cinahl, PubMed, ProQuest, ScienceDirect, Scopus and Cochrane databases were searched for studies on adults, cadavers, and animal models. Pediatric studies were excluded. EVIDENCE SYNTHESIS: The search strategy found 598 citations. Following screening, 19 studies were selected. Intraneural injections occurred in the brachial plexus, sciatic, femoral, and median nerves. Subparaneural injections in popliteal, supraclavicular and interscalene blocks. Sixteen different ultrasound findings were used to label injection location. Subepineural deposits within individual nerves occurred occasionally following subparaneural injections, regardless of nerve expansion. Overall, five studies reported intrafascicular deposits, two of which frequently, following intraneural and subparaneural injections. None of the currently used ultrasound findings was predictive of intrafascicular deposits. CONCLUSIONS: Our results suggest that sonographic parameters of intraneural and subparaneural injections are reliable in terms of detecting spread location. Intrafascicular injectate deposition may occur, albeit infrequently, particularly in the proximal brachial plexus. Our findings support the judicious interrogation of sonographic parameters suggestive of incipient intraneural injection.

Characteristics and influence on quality of life of new-onset pain in critical COVID-19 survivors.

BACKGROUND: Pain is a clinical feature of COVID-19, however, data about persistent pain after hospital discharge, especially among ICU survivors is scarce. The aim of this study was to explore the incidence and characteristics of new-onset pain and its impact on Health-Related Quality of Life (HRQoL), and to quantify the presence of mood disorders in critically ill COVID-19 survivors. METHODS: This is a preliminary report of PAIN-COVID trial (NCT04394169) presenting a descriptive analysis in critically ill COVID-19 survivors, following in person interview 1 month after hospital discharge. Pain was assessed using the Brief Pain Inventory, the Douleur Neuropathique 4 questionnaire and the Pain Catastrophizing Scale. HRQoL was evaluated with the EQ 5D/5L, and mood disorders with the Hospital Anxiety and Depression Scale (HADS). RESULTS: From 27 May to 19 July 2020, 203 patients were consecutively screened for eligibility, and 65 were included in this analysis. Of these, 50.8% patients reported new-onset pain; 38.5% clinically significant pain (numerical rating score ≥3 for average pain intensity); 16.9% neuropathic pain; 4.6% pain catastrophizing thoughts, 44.6% pain in ≥2 body sites and 7.7% widespread pain. Patients with new-onset pain had a worse EQ-VAS and EQ index value (p < 0.001). Pain intensity was negatively correlated to both the former (Spearman ρ: -0.546, p < 0.001) and the latter (Spearman ρ: -0.387, p = 0.001). HADS anxiety and depression values equal or above eight were obtained in 10.8% and 7.7% of patients, respectively. CONCLUSION: New-onset pain in critically ill COVID-19 survivors is frequent, and it is associated with a lower HRQoL. Trial registration No.: NCT04394169. Registered 19 May 2020. https://clinicaltrials.gov/ct2/show/NCT04394169. SIGNIFICANCE: A substantial proportion of severe COVID-19 survivors may develop clinically significant persistent pain, post-intensive care syndrome and chronic ICU-related pain. Given the number of infections worldwide and the unprecedented size of the population of critical illness survivors, providing information about the incidence of new-onset pain, its characteristics, and its influence on the patients' quality of life might help establish and improve pain management strategies.

Rationale and study design of an early care, therapeutic education, and psychological intervention program for the management of post-intensive care syndrome and chronic pain after COVID-19 infection (PAIN-COVID): study protocol for a randomized controlled trial.

BACKGROUND: Critically ill patients with COVID-19 are an especially susceptible population to develop post-intensive care syndrome (PICS) due to acute respiratory distress syndrome (ARDS). Patients can suffer acute severe pain and may have long-term mental, cognitive, and functional health deterioration after discharge. However, few controlled trials are evaluating interventions for the prevention and treatment of PICS. The study hypothesis is that a specific care program based on early therapeutic education and psychological intervention improves the quality of life of patients at risk of developing PICS and chronic pain after COVID-19. The primary objective is to determine whether the program is superior to standard-of-care on health-related quality of life at 6 months after hospital discharge. The secondary objectives are to determine whether the intervention is superior to standard-of-care on health-related quality of life, incidence of chronic pain and degree of functional limitation, incidence of anxiety, depression, and post-traumatic stress syndrome at 3 and 6 months after hospital discharge. METHODS: The PAINCOVID trial is a unicentric randomized, controlled, patient-blinded superiority trial with two parallel groups. The primary endpoint is the health-related quality of life at 6 months after hospital discharge, and randomization will be performed with a 1:1 allocation ratio. This paper details the methodology and statistical analysis plan of the trial and was submitted before outcome data were available. The estimated sample size is 84 patients, 42 for each arm. Assuming a lost to follow-up rate of 20%, a sample size of 102 patients is necessary (51 for each arm). DISCUSSION: This is the first randomized clinical trial assessing the effectiveness of an early care therapeutic education, and psychological intervention program for the management of PICS and chronic pain after COVID-19. The intervention will serve as proof of the need to implement early care programs at an early stage, having an incalculable impact given the current scenario of the pandemic. TRIAL REGISTRATION: This study is being conducted in accordance with the tenets of the Helsinki Declaration and has been approved by the authors' institutional review board Comité Ético de Investigación Clínica del Hospital Clínic de Barcelona (approval number: HCB/2020/0549) and was registered on May 9, 2020, at clinicaltrials.gov ( NCT04394169 ).

Ultrasound-guided genicular nerves block: an analgesic alternative to local infiltration analgesia for total knee arthroplasty: A noninferiority, matched cohort study.

BACKGROUND: Standard analgesic strategies for total knee arthroplasty employ local infiltration analgesia. Blockade and radiofrequency ablation of the genicular nerves are effective treatments for patients with chronic pain because of knee osteoarthritis. OBJECTIVE: To test the noninferiority of the analgesic effect of genicular nerves block in comparison with local infiltration analgesia after 24 h of total knee arthroplasty. DESIGN: Prospective cohort study. SETTING: Perioperative setting. PATIENTS: Thirty-five patients scheduled for total knee arthroplasty were prospectively included in the study and compared with 35 patients in a retrospective cohort. INTERVENTION: Genicular nerve blocks in the prospective cohort were compared with local infiltration analgesia in the retrospective cohort. MAIN OUTCOME MEASURES: The pain numeric rating scale and the cumulative opioid consumption in oral morphine equivalents during the first 24 h. RESULTS: We conducted propensity score-matched analyses of patients using acute postoperative pain-related risk covariates. After one-to-one propensity score matching, 21 patients were included in the local infiltration analgesia group and 21 in the genicular nerve block group. The median difference in numeric rating score at rest at 24 h was -0.99 [95% confidence interval (CI), -1.99 to 0.5, P = 0.012] on the unmatched cohort and -1.9 (95% CI, -2 to 0, P = 0.002) on the matched cohort (meeting the noninferiority criteria, Δ=1). The median difference in cumulative opioid consumption was 2.5 mg (95% CI, -13.5 to 2.5, P < 0.001) for the unmatched cohort and 4.99 mg (95% CI, -11.5 to 2.5, P < 0.001) on the matched group (meeting the noninferiority criteria, Δ = 21 mg). CONCLUSION: Local infiltration analgesia and genicular nerve block are comparable in terms of analgesic results. Therefore, genicular nerves block is an alternative to local infiltration analgesia in patients undergoing total knee arthroplasty. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04024319.