No Benefit of Adductor Canal Block Compared with Anterior Local Infiltration Analgesia in Primary Total Knee Arthroplasty: A Single-Blinded Randomized Controlled Clinical Trial.

BACKGROUND: An adductor canal block (ACB) performed by an anesthesiologist is an established component of analgesia after total knee arthroplasty. Alternatively, surgeons may perform periarticular local infiltration analgesia (LIA) intraoperatively. We hypothesized that ACB would be superior to anterior LIA in terms of morphine consumption in the first 48 hours after primary total knee arthroplasty under spinal anesthesia. METHODS: This prospective controlled and blinded trial included 98 patients; 48 received an ACB plus sham (saline solution) anterior LIA, and 50 received a sham (saline solution) ACB plus anterior LIA. Both groups received posterior LIA with local anesthetic. The primary outcome was cumulative morphine consumption at 48 hours after surgery. Secondary outcomes were pain while resting, standing, and walking, rehabilitation scores, opioid-related side effects, and patient satisfaction. RESULTS: No difference in the primary outcome was found, and the 48-hour morphine consumption was low in both arms (28.8 ± 17.6 mg with ACB, 26.8 ± 19.2 mg with anterior LIA; p = 0.443). Pain scores were significantly better in the anterior LIA arm, but the differences were not clinically relevant. There were no differences in any other secondary outcome measures. CONCLUSIONS: LIA may be used as the primary option for multimodal postoperative pain management in patients undergoing primary total knee arthroplasty with spinal anesthesia. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Outcomes in Patients Who Received Spinal Chloroprocaine for Total Hip or Knee Arthroplasty-Consecutive Case Series Study.

Spinal anaesthesia is an established component of perioperative management for fast-track lower limbs arthroplasty. Short-acting local anaesthetics may present an interesting option for primary non-complicated knee (TKA) and hip (THA) arthroplasty. We describe the perioperative outcomes in patients operated under fixed 50 mg spinal chloroprocaine for total hip and knee replacement. In this retrospective case series study, 65 patients were analysed (median age 65 years, 55% females, benefit from THA (n = 31), TKA (n = 25), and unicompartmental knee arthroplasty (n = 9)). In all cases, anaesthesia duration (87 min) was sufficient for successful surgery (52 min). Up to 45% of patients (THA and less in TKA) developed postoperative pain in the post-anaesthesia care unit (PACU), requiring intravenous morphine titration (up to 7.5 mg). One patient developed severe breakthrough pain requiring advanced regional analgesia. The median PACU stay was up to 97 min (less in TKA), and the incidence of nausea and urinary retention was low. All patients were able to start physical therapy on the same day of surgery. These findings encourage the use of a short-acting agent for spinal anaesthesia in patients with primary non-complicated arthroplasty; however, the relay analgesia should be systematically implemented to avoid breakthrough pain in PACU.

Preoperative Education for Less Outpatient Pain after Surgery (PELOPS trial) in orthopedic patients-study protocol for a randomized controlled trial.

BACKGROUND: Successful pain management after outpatient surgery requires proper education leading to correct decisions on the analgesics use at home. Despite different strategies adopted, up to ½ of patients receive little or no information about the treatment of postoperative pain, 1/3 of them are not able to follow postoperative analgesia instructions. This leads to higher rates of unmet needs in pain treatment, post-discharge emergency calls, and readmissions. Structured educational interventions using psychological empowering techniques may improve postoperative pain management. We hypothesize that preoperative education on use of an improved pain scale to make correct pain management decisions will improve the quality of post-operative pain management at home and reduce analgesics-related side effects. METHODS: A total of 414 patients scheduled for an outpatient orthopedic surgery (knee/shoulder arthroscopic interventions) are included in this randomized (1:1) controlled trial. Patients in the control arm receive standard information on post-discharge pain management. Patients in the experimental arm receive structured educational intervention based on the rational perception of postoperative pain and discomfort (anchoring and improved pain scale), and the proper use of analgesics. There is no difference in post-discharge analgesics regimen in both arms. Patients are followed for 30 days post-discharge, with the primary outcome expressed as total pain relief score at 5 days. Secondary outcomes include the incidence of severe pain during 30 days, changes in sleep quality (Pittsburg Sleep Quality Assessment), and patients' perception of postoperative pain management assessed with the International Pain Outcomes questionnaire at day 30 post-discharge. DISCUSSION: The developed intervention, based on an improved pain scale, offers the advantages of being non-surgery-specific, is easily administered in a short amount of time, and can be delivered individually or in-group, by physicians or nurses. TRIAL REGISTRATION: ClinicalTrials.gov NCT03754699 . Registered on November 27, 2018.

Usability evaluation of sufentanil sublingual tablet analgesia in patients following Enhanced Recovery After Surgery.

Aim: To evaluate the usability and satisfaction from the sufentanil sublingual tablet system analgesia in the Enhanced Recovery After Surgery pathway in patients, nurses and physical therapist. Materials & methods: A system usability scale was used to evaluate analgesia system in the prospective observational study in spine, orthopedic and thoracic patients. Result: In 111 cases the median system usability scale score was 90 (80-100) (patients) and 72.5 (57.5-82.5) (nurses). The median satisfaction score of the physiotherapist was 90 (75-100). Conclusion: The usability and the satisfaction of the patients and the caregivers from sufentanil sublingual tablet system analgesia in the context of Enhanced Recovery After Surgery protocol were good-to-excellent. The economic potential in the reduction of hospital stay should be studied. Trial registration number: NCT03373851 (ClinicalTrial.gov).

Anemia before reimplantation surgery - An overlooked modifiable risk factor of septic revision knee arthroplasty failure.

INTRODUCTION: Preoperative anemia in patients undergoing a two-stage septic revision arthroplasty may be a factor of reinfection, even in the presence of aggressive antimicrobial therapy. Patient Blood Management (PBM) in such patients is challenging. We evaluate the impact of anemia existing before re-implantation on a failure rate after two-stage septic total knee arthroplasty (rTKA), and explore feasibility of a PBM strategy implementation in these patients. MATERIALS AND METHODS: A retrospective study of patients from January 2010 to January 2015 in a French regional referral center was performed. Patients undergoing a two-stage rTKA for infection after successful primary TKA were identified and followed up to 31.12.2018. The primary outcome (failure) was defined as surgical site infection after re-implantation requiring new surgery. The secondary outcomes were time to failure, the time between explantation/reimplantation, transfusion rate during the second stage. Preoperative anemia was defined as Hb level < 12 g/L before the re-implantation. RESULTS: 69 patients were identified; 17 (24%) developed reinfection of rTKA in 105 [11.4-156] days. In these patients pre-implantation anemia was more frequent (n = 13(76.5%) in failed vs. n = 21(40%) in non-failed, p = 0.0110). During the explantation stage, there were no significant group differences in age, sex, comorbidity, type of spacer and antimicrobial therapy, iron supplementation, or transfusion rate. The median time between explantation/reimplantation surgery was 51 [43-71.5] days, indifferent between the two groups. Intraoperative transfusion during reimplantation was required in 12 (17%) patients, more frequent in failed patients. None of the patients had contraindications for the PBM strategy except the cell-saver use. CONCLUSION: In two-stage septic rTKA preoperative anemia was almost two times more frequent and associated with an elevated rate of septic failure. The time-frame between explantation and-re-implantation is sufficient to implement a PBM strategy for all anemic patients. Before-after studies would be of interest to determine the best PBM strategy to prevent anemia-associated septic failure in such a condition.

Management of postdischarge nausea and vomiting.

Postdischarge nausea and vomiting (PDNV) occurs in at least 30% of patients leaving hospital, especially after day-case surgery. A significant number of ambulatory patients may develop PDNV associated with the use of analgesics for postsurgical pain. A validated PDNV prediction score and international evidence-based consensus guidelines for PONV/PDNV management are available. High-risk patients benefit from a predischarge PDNV risk assessment and the use of adapted pharmacological intervention (combination of long- and short-acting antiemetics and access to antiemetics at home). Patient education is often overlooked in this context. All clinicians involved in the ambulatory surgery care process should participate in the development of institutional protocol for PONV/PDNV management. Constant quality control and patients' feedback should be integrated as part of an efficient implementation strategy.

Causes and mechanisms of isolated mitral regurgitation in the community: clinical context and outcome.

AIMS: To define the hitherto unknown aetiology/mechanism distributions of mitral regurgitation (MR) in the community and the linked clinical characteristics/outcomes. METHODS AND RESULTS: We identified all isolated, moderate/severe MR diagnosed in our community (Olmsted County, MN, USA) between 2000 and 2010 and classified MR aetiology/mechanisms. Eligible patients (n = 727) were 73 ± 18 years, 51% females, with ejection fraction (EF) 49 ± 17%. MR was functional (FMR) in 65%, organic (OMR) in 32% and 2% mixed. Functional MR was linked to left ventricular remodelling (FMR-v) 38% and isolated atrial dilatation (FMR-a) 27%. At diagnosis FMR-v vs. FMR-a, vs. OMR displayed profound differences (all P < 0.0001) in age (73 ± 14, 80 ± 10, 68 ± 21years), male-sex (59, 33, 51%), atrial-fibrillation (28, 54, 13%), EF (33 ± 14, 57 ± 11, 61 ± 10%), and regurgitant-volume (38 ± 13, 37 ± 11, 51 ± 24 mL/beat). Dominant MR mechanism was Type I (normal valve-movement) 38%, Type II (excessive valve-movement) 25%, Type IIIa (diastolic movement-restriction) 3%, and Type IIIb (systolic movement-restriction) 34%. Outcomes were mediocre with excess-mortality vs. general-population in FMR-v [risk ratio 3.45 (2.98-3.99), P < 0.0001] but also FMR-a [risk ratio 1.88 (1.52-2.25), P < 0.0001] and OMR [risk ratio 1.83 (1.50-2.22), P < 0.0001]. Heart failure was frequent, particularly in FMR-v (5-year 83 ± 3% vs. 59 ± 4% FMR-a, 40 ± 3% OMR, P < 0.0001). Mitral surgery during patients' lifetime was performed in 4% of FMR-v, 3% of FMR-a, and 37% of OMR. CONCLUSION: Moderate/severe isolated MR in the community displays considerable aetiology/mechanism heterogeneity. Functional MR dominates, mostly FMR-v but FMR-a is frequent and degenerative MR dominates OMR. Outcomes are mediocre with excess-mortality particularly with FMR-v but FMR-a, despite normal EF incurs notable excess-mortality and frequent heart failure. Pervasive undertreatment warrants clinical trials of therapies tailored to specific MR cause/mechanisms.

[Topical application of analgesic cream for spinal anaesthesia in elective orthopaedic surgery]. / Pose de pommade analgésique pour rachianesthésie en chirurgie orthopédique programmée.

Lidocaine-Prilocaine (Emla®) analgesic cream is commonly used for pain relief during puncture in patients receiving spinal anaesthesia. The protocols for this procedure vary widely. A study was conducted in elective orthopaedic surgery to determine the factors influencing the quality of application and those that improve it.

Outcome and undertreatment of mitral regurgitation: a community cohort study.

BACKGROUND: Mitral regurgitation is the most common valve disease worldwide but whether the community-wide prevalence, poor patient outcomes, and low rates of surgical treatment justify costly development of new therapeutic interventions remains uncertain. Therefore, we did an observational cohort study to assess the clinical characteristics, outcomes, and degree of undertreatment of mitral regurgitation in a community setting. METHODS: We used data from Mayo Clinic electronic health records and the Rochester Epidemiology Project to identify all cases of moderate or severe isolated single-valvular mitral regurgitation (with no other severe left-sided valvular disease or previous mitral surgery) diagnosed during a 10-year period in the community setting in Olmsted County (MN, USA). We assessed clinical characteristics, mortality, heart failure incidence, and results of cardiac surgery post-diagnosis. FINDINGS: Between Jan 1, 2000, and Dec 31, 2010, 1294 community residents (median age at diagnosis 77 years [IQR 66-84]) were diagnosed with moderate or severe mitral regurgitation by Doppler echocardiography (prevalence 0·46% [95% CI 0·42-0·49] overall; 0·59% [0·54-0·64] in adults). Left-ventricular ejection fraction below 50% was frequent (recorded in 538 [42%] patients), and these patients had a slightly lower regurgitant volume than those with an ejection fraction of 50% or higher (mean 39 mL [SD 16] vs 45 mL [21], p<0·0001). Post-diagnosis mortality was mainly cardiovascular in nature (in 420 [51%] of 824 patients for whom the cause of death was available) and higher than expected for residents of the county for age or sex (risk ratio [RR] 2·23 [95% CI 2·06-2·41], p<0·0001). This excess mortality affected all subsets of patients, whether they had a left-ventricular ejection fraction lower than 50% (RR 3·17 [95% CI 2·84-3·53], p<0·0001) or of 50% or higher (1·71 [1·53 -1·91], p<0·0001) and with primary mitral regurgitation (RR 1·73 [95% CI 1·53-1·96], p<0·0001) or secondary mitral regurgitation (2·72 [2·48-3·01], p<0·0001). Even patients with a low comorbidity burden combined with favourable characteristics such as left-ventricular ejection fraction of 50% or higher (RR 1·28 [95% CI 1·10-1·50], p<0·0017) or primary mitral regurgitation (1·29 [1·09-1·52], p=0·0030) incurred excess mortality. Heart failure was frequent (mean 64% [SE 1] at 5 years postdiagnosis), even in patients with left-ventricular ejection fraction of 50% or higher (49% [2] at 5 years postdiagnosis) or in those with primary mitral regurgitation (48% [2]). Mitral surgery was ultimately done in only 198 (15%) of 1294 patients, of which the predominant type of surgery was valve repair (in 149 [75%] patients). Mitral surgery was done in 28 (5%) of 538 patients with left-ventricular ejection fraction below 50% and in 170 (22%) of 756 patients with ejection fraction of 50% or higher, and in 34 (5%) of 723 with secondary mitral regurgitation versus 164 (29%) of 571 with primary regurgitation. All other types of cardiac surgery combined were performed in only 3% more patients (237 [18%] patients) than the number who underwent mitral surgery. INTERPRETATION: In the community, isolated mitral regurgitation is common and is associated with excess mortality and frequent heart failure postdiagnosis in all patient subsets, even in those with normal left-ventricular ejection fraction and low comorbidity. Despite these poor outcomes, only a minority of affected patients undergo mitral (or any type of cardiac) surgery even in a community with all means of diagnosis and treatment readily available and accessible. This suggests that in a wider population there might be a substantial unmet need for treatment for this disorder. FUNDING: Mayo Clinic Foundation.

Potentially Modifiable Risk Factors for Long-Term Cognitive Impairment After Critical Illness: A Systematic Review.

Long-term cognitive impairment is common in survivors of critical illness. Little is known about the etiology of this serious complication. We sought to summarize current scientific knowledge about potentially modifiable risk factors during intensive care unit (ICU) treatment that may play a substantial role in the development of long-term cognitive impairment. All searches were run on October 1, 2017. The search strategy included Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effect, Scopus, and Web of Science, and included MeSH headings and keywords related to intensive care, critical care, and cognitive disorders. Searches were restricted to adult subjects. Inclusion required follow-up cognitive evaluation at least 2 months after ICU discharge. Studies assessing patients with cardiac arrest, traumatic brain injury, and cardiac surgery history were excluded. The search strategy resulted in 3180 studies. Of these, 28 studies (.88%) met our inclusion criteria and were analyzed. Delirium and duration of delirium were associated with long-term cognitive impairment after ICU admission in 6 of 9 studies in which this factor was analyzed. Weaker and more inconsistent associations have been reported with hypoglycemia, hyperglycemia, fluctuations in serum glucose levels, and in-hospital acute stress symptoms. Instead, most of the studies did not find significant associations between long-term cognitive impairment and mechanical ventilation; use of sedatives, vasopressors, or analgesic medications; enteral feeding; hypoxia; extracorporeal membrane oxygenation; systolic blood pressure; pulse rate; or length of ICU stay. Prolonged delirium may be a risk factor for long-term cognitive impairment after critical illness, though this association has not been entirely consistent across studies. Other potentially preventable factors have not been shown to have strong or consistent associations with long-term cognitive dysfunction in survivors of critical illness.

Decision Support Tool to Improve Glucose Control Compliance After Cardiac Surgery.

Hyperglycemia control is associated with improved outcomes in patients undergoing cardiac surgery. The Surgical Care Improvement Project metric (SCIP-inf-4) was introduced as a performance measure in surgical patients and included hyperglycemia control. Compliance with the SCIP-inf-4 metric remains suboptimal. A novel real-time decision support tool (DST) with guaranteed feedback that is based on the existing electronic medical record system was developed at a tertiary academic center. Implementation of the DST increased the compliance rate with the SCIP-inf-4 from 87.3% to 96.5%. Changes in tested clinical outcomes were not observed with improved metric compliance. This new framework can serve as a backbone for development of quality control processes for other metrics. Further and, ideally, multicenter studies are required to test if implementation of electronic DSTs will translate into improved resource utilization and outcomes for patients.

Suprazygomatic Access for Continuous Bilateral Mandibular Nerve Block for Pain and Trismus Relief in the Tetraplegic Patient.

PURPOSE: Extraoral mandibular nerve block (MNB) is used in oropharyngeal surgery for analgesia and anesthesia. Repeated or continuous MNB has been used successfully as treatment for uncontrollable pain, masseter spasticity, and airway assessment. The usual technique involves transcutaneous infrazygomatic access. However, in some specific settings, this approach is not always feasible. MATERIALS AND METHODS: A continuous bilateral MNB with a suprazygomatic approach to the pterygomandibular space was used to resolve a case of refractory and painful trismus in a patient with tetraplegia. RESULTS: Analgesia was achieved and maintained by bilateral catheter placement to the pterygomandibular space and repeated injection of local anesthetic for 48 hours. The right-side catheter was accidentally withdrawn; the left-side catheter was maintained up to 72 hours. The efficiency of analgesia was not affected. This block provided effective analgesia within the first few hours after local anesthetic injection, helped to improve mouth opening, and resolved acute pain. Because kinesitherapy could be introduced, the patient was left on nonopioid analgesics. CONCLUSION: Continuous bilateral MNB through the suprazygomatic approach was used safely and efficiently. The suggested approach is quite unique, as is the clinical circumstance, and might be considered when the usual technique is challenging.

Systematic Review of the Use of Phytochemicals for Management of Pain in Cancer Therapy.

Pain in cancer therapy is a common condition and there is a need for new options in therapeutic management. While phytochemicals have been proposed as one pain management solution, knowledge of their utility is limited. The objective of this study was to perform a systematic review of the biomedical literature for the use of phytochemicals for management of cancer therapy pain in human subjects. Of an initial database search of 1,603 abstracts, 32 full-text articles were eligible for further assessment. Only 7 of these articles met all inclusion criteria for this systematic review. The average relative risk of phytochemical versus control was 1.03 [95% CI 0.59 to 2.06]. In other words (although not statistically significant), patients treated with phytochemicals were slightly more likely than patients treated with control to obtain successful management of pain in cancer therapy. We identified a lack of quality research literature on this subject and thus were unable to demonstrate a clear therapeutic benefit for either general or specific use of phytochemicals in the management of cancer pain. This lack of data is especially apparent for psychotropic phytochemicals, such as the Cannabis plant (marijuana). Additional implications of our findings are also explored.