Association of chronic poststernotomy pain and health-related quality of life: a prospective cohort study.

PURPOSE: Chronic poststernotomy pain (CPSP) after cardiac surgery is multifactorial and impacts patient recovery. We aimed to evaluate the association between CPSP severity and health-related quality of life at six months after cardiac surgery. METHODS: This was a single-centre prospective cohort study of patients who underwent cardiac surgery with median sternotomy between September 2020 and March 2021. Telephone interviews were conducted at six and 12 months postoperatively using the Short Form McGill Pain Questionnaire and the EQ-5D-5L. Strength of correlation was described using Spearman's correlation coefficient. Multivariable regression analysis was used to account for confounding variables. RESULTS: A total of 252 patients responded to the six-month interview (response rate, 65%). The mean (standard deviation) age of respondents was 65 (13) yr. Twenty-nine percent of respondents (72/252) reported CPSP at six months, and 14% (41/252) reported more than mild pain (score ≥ 2/5). At 12 months, of the 89% (64/72) patients who responded, 47% (30/64) still reported pain. The strength of the correlation between pain scores and EQ-5D-5L was weak (Spearman's correlation coefficient, -0.3). Risk factors for CPSP at six months included higher pain score on postoperative day 1, history of chronic pain prior to surgery, and history of depression. Intraoperative infusion of dexmedetomidine or ketamine was associated with a reduced risk of CPSP at six months. CONCLUSION: Chronic poststernotomy pain still affects patient recovery at six and 12 months after cardiac surgery. The severity of that pain is poorly correlated with patients' quality of life. STUDY REGISTRATION: www.osf.io ( https://osf.io/52rsw ); registered 14 May 2022.

RéSUMé: OBJECTIF: La douleur chronique post-sternotomie (DCPS) après une chirurgie cardiaque est multifactorielle et a un impact sur le rétablissement des patient·es. Nous avons cherché à évaluer l'association entre la sévérité de la DCPS et la qualité de vie liée à la santé six mois après la chirurgie cardiaque. MéTHODE: Il s'agissait d'une étude de cohorte prospective monocentrique portant sur des patient·es ayant bénéficié d'une chirurgie cardiaque avec sternotomie médiane entre septembre 2020 et mars 2021. Des entrevues téléphoniques ont été menées à six et 12 mois après l'opération en se servant du questionnaire abrégé de McGill sur la douleur et de l'EQ-5D-5L. La force de corrélation a été décrite à l'aide du coefficient de corrélation de Spearman. Une analyse de régression multivariée a été utilisée pour tenir compte des variables confondantes. RéSULTATS: Au total, 252 patient·es ont répondu à l'entrevue à six mois (taux de réponse de 65 %). L'âge moyen (écart type) des répondant·es était de 65 (13) ans. Vingt-neuf pour cent des personnes répondantes (72/252) ont déclaré avoir été atteintes de DCPS à six mois, et 14 % (41/252) ont signalé une douleur plus que légère (score ≥ 2/5). À 12 mois, sur les 89 % (64/72) personnes ayant répondu, 47 % (30/64) signalaient encore de la douleur. La force de la corrélation entre les scores de douleur et l'EQ-5D-5L était faible (coefficient de corrélation de Spearman, −0,3). Les facteurs de risque de DCPS à six mois comprenaient un score de douleur plus élevé au jour 1 postopératoire, des antécédents de douleur chronique avant la chirurgie et des antécédents de dépression. Une perfusion peropératoire de dexmédétomidine ou de kétamine a été associée à une réduction du risque de DCPS à six mois. CONCLUSION: La douleur chronique post-sternotomie affecte toujours le rétablissement des patient·es six et 12 mois après la chirurgie cardiaque. La sévérité de cette douleur est faiblement corrélée à la qualité de vie des patient·es. ENREGISTREMENT DE L'éTUDE: www.osf.io ( https://osf.io/52rsw ); enregistrée le 14 mai 2022.

Current Recommendations for Perioperative Brain Health: A Scoping Review.

Perioperative complications such as stroke, delirium, and neurocognitive dysfunction are common and responsible for increased morbidity and mortality. Our objective was to characterize and synthesize the contemporary guidelines on perioperative brain health for noncardiac, non-neurologic surgery in a scoping review. We performed a structured search for articles providing recommendations on brain health published between 2016 and 2021 and included the following complications: perioperative stroke and perioperative neurocognitive disorders, the latter of which encompasses postoperative delirium and a spectrum of postoperative cognitive dysfunction. We categorized recommendations by subtopic (stroke, postoperative delirium, postoperative cognitive dysfunction), type (disclosure/ethics/policies, prevention, risk stratification, screening/diagnosis, and management), and pharmacological versus nonpharmacological strategies. We noted country of origin, specialty of the authors, evidence grade (if available), and concordance/discordance between recommendations. Eight publications provided 129 recommendations, originating from the United States (n=5), Europe (n=1), United Kingdom (n=1), and China (n=1). Three publications (37%) applied grading of evidence as follows: Grading of Recommendations, Assessment, Development, and Evaluations (GRADE): A, 30%; B, 36%; C, 30%; D, 4%. We identified 42 instances of concordant recommendations (≥2 publications) on 15 themes, including risk factor identification, risk disclosure, baseline neurocognitive testing, nonpharmacological perioperative neurocognitive disorder prevention, intraoperative monitoring to prevent perioperative neurocognitive disorders, avoidance of benzodiazepines, delaying elective surgery after stroke, and emergency imaging and rapid restoration of cerebral perfusion after perioperative stroke. We identified 19 instances of discordant recommendations on 7 themes, including the use of regional anesthesia and monitoring for perioperative stroke prevention, pharmacological perioperative neurocognitive disorder management, and postoperative stroke screening. We synthesized recommendations for clinical practice and highlighted areas where high-quality evidence is required to inform best practices in perioperative brain health.

Association of anaesthesia technique with 30-day primary graft patency after open lower limb revascularization: retrospective cohort study.

BACKGROUND: The relationship between anaesthetic technique and graft patency after open lower limb revascularization is unclear. The aim of this study was to evaluate the association between 30-day graft patency after elective infrainguinal bypass and anaesthetic technique (regional anaesthesia (RA, i.e. neuraxial and/or peripheral nerve blockade) compared with general anaesthesia (GA)). METHODS: Patients who underwent elective infrainguinal bypass in the 2014-2019 National Surgical Quality Improvement Program Vascular Procedure Targeted Lower Extremity Open data set were included. Excluded patients were those under 18 years old, those who did not receive RA or GA, and/or had an international normalized ratio of 1.5 of greater, a partial thromboplastin time more than 35 s, or a platelet count less than 80 × 109/L. The primary outcome was primary graft patency without reintervention. The relationship between anaesthetic technique and patency was analysed with multivariable logistic regression. RESULTS: Included were 8893 patients with a mean(s.d.) age of 68(11) years and 31.5 per cent female. Within the cohort, 7.7 per cent (n = 688) patients received RA only, 90.4 per cent (n = 8039) GA only, and 1.9 per cent (n = 166) both GA and RA. In the RA-only group, 91.7 per cent (631 of 688) received neuraxial anaesthesia. The primary patency rate was 93.2 per cent (573 of 615) for RA only, and 91.5 per cent (6390 of 6983) for GA only (standardized mean difference, 0.063). RA was not associated with a higher rate of patency compared with GA (adjusted OR, 1.16; 95 per cent c.i., 0.83 to 1.63; P = 0.378). CONCLUSION: There was no association between anaesthetic technique and 30-day graft patency after elective infrainguinal bypass surgery. Further prospective studies would be useful to study the impact of anaesthesia technique on important patient-centred outcomes such as long-term patency and non-home discharge.

Trends in opioid dispensing after common abdominal and orthopedic surgery procedures in British Columbia: a retrospective cohort analysis.

PURPOSE: Postdischarge opioid prescriptions are reportedly much higher in Canada than in other countries. To assess potentially contributing factors, we examined trends after abdominal and orthopedic surgeries in British Columbia (BC). METHODS: Using the BC Ministry of Health's databases on physician billings, hospital discharge abstracts, and medication dispensations in community pharmacies for the period 2003-2016, we assembled a cohort of 263,056 patients who received laparoscopic appendectomy (LA, 11%), laparoscopic cholecystectomy (LC, 30%), open inguinal or femoral hernia repair (IHR, 20%), total hip arthroplasty (THA, 18%), or total knee arthroplasty (TKA, 22%). Adjusting for covariates using generalized linear modeling, we measured trends in percentages of patients dispensed opioids postdischarge (opioid rate) within 30 days after surgery, by surgery type, opioid type, prior use, surgeon, and trends in morphine milligram equivalents of first dispensations (MME) with 95% confidence intervals (CI). RESULTS: Opioid dispensation rates rose steadily. Mean annual increases were 1.7% in LA; 1.3% in LC; 0.8% in IHR; 0.9% in THA; and 0.8% in TKA. By 2016, rates were 69% in LA; 76% in LC; 81% in IHR; 88% in THA; and 94% in TKA. Codeine dispensations fell 2.4% (abdominal) and 3.1% (orthopedic) per year while tramadol dispensations increased 3.6% (abdominal) and 1.7% (orthopedic). Hydromorphone dispensations increased 2.9% per year (orthopedic); oxycodone was level at 22% between 2007 and 2014, but then fell. The mean MME rose 8 mg⋅yr-1 (95% CI, 7 to 9) (abdominal) and 61 mg⋅yr-1 (95% CI, 58 to 64) (orthopedic). Variation in rates was greater among abdominal than orthopedic surgeons. CONCLUSION: Rising opioid dispensation rates, together with shifts to prescribing higher MME opioids, doubled MME per patient in first dispensations postdischarge after abdominal or orthopedic surgery from 2003 to 2016 in BC.

RéSUMé: OBJECTIF: Les ordonnances d'opioïdes après le congé seraient beaucoup plus élevées au Canada que dans d'autres pays. Afin d'évaluer les facteurs contributifs potentiels, nous avons examiné les tendances après les chirurgies abdominales et orthopédiques en Colombie-Britannique (C.-B.). MéTHODE: En utilisant les bases de données du ministère de la Santé de la Colombie-Britannique de facturation des médecins, les résumés des congés d'hôpital et les délivrances de médicaments dans les pharmacies communautaires pour la période 2003-2016, nous avons regroupé une cohorte de 263 056 patients ayant bénéficié d'une appendicectomie par laparoscopie (AL, 11 %), d'une cholécystectomie par laparoscopie (CL, 30 %), d'une réparation ouverte de hernie inguinale ou fémorale (RHI, 20 %), d'une arthroplastie totale de la hanche (ATH, 18 %) ou d'une arthroplastie totale du genou (ATG, 22 %). En tenant compte des covariables à l'aide d'une modélisation linéaire généralisée, nous avons mesuré les tendances dans les pourcentages de patients ayant reçu des opioïdes après leur congé (taux de délivrance d'opioïdes) dans les 30 jours suivant leur chirurgie, par type de chirurgie, type d'opioïde, utilisation antérieure, chirurgien et tendances des équivalents de morphine en milligrammes (EMM) des premières délivrances avec des intervalles de confiance (IC) à 95 %. RéSULTATS: Les taux de délivrance d'opioïdes ont augmenté de manière constante. Les augmentations annuelles moyennes étaient de 1,7 % pour les AL, 1,3 % pour les CL, 0,8 % pour les RHI, 0,9 % pour les ATH, et 0,8 % pour les ATG. En 2016, les taux étaient de 69 % pour les AL, 76 % pour les CL, 81 % pour les RHI, 88 % pour les ATH, et 94 % pour les ATG. Les dispenses de codéine ont chuté de 2,4 % (chirurgie abdominale) et de 3,1 % (chirurgie orthopédique) par année, tandis que les délivrances de tramadol ont augmenté de 3,6 % (chirurgie abdominale) et de 1,7 % (chirurgie orthopédique). Les délivrances d'hydromorphone ont augmenté de 2,9 % par année (orthopédie); l'oxycodone était à 22 % entre 2007 et 2014, mais a ensuite diminué. Les EMM moyens ont augmenté de 8 mg·an-1 (IC 95 %, 7 à 9) (chirurgie abdominale) et de 61 mg·an-1 (IC 95 %, 58 à 64) (chirurgie orthopédique). La variation des taux était plus importante parmi les chirurgiens abdominaux que chez les chirurgiens orthopédistes. CONCLUSION: L'augmentation des taux de délivrance d'opioïdes, ainsi que le passage à une prescription d'opioïdes plus élevés en EMM, ont doublé les EMM par patient dans les premières délivrances après leur congé après une chirurgie abdominale ou orthopédique de 2003 à 2016 en Colombie-Britannique.

Opioid dispensing after Cesarean delivery in British Columbia: a historical cohort analysis from 2004 to 2019.

PURPOSE: To describe postdischarge opioid dispensing after Cesarean delivery (CD) in 49 hospitals in British Columbia (BC) and assess opportunities for opioid stewardship. METHODS: Using the BC Ministry of Health's Hospital Discharge Abstract Database, we linked 135,725 CDs performed in 2004-2016 and 30,919 CDs performed in 2017-2019 (length of stay ≤ four days) by deidentified Personal Health Numbers to data on medications dispensed from all BC community pharmacies (PharmaNet). We excluded patients with cancer and those to whom opioids have been dispensed in the year before. We measured trends in annual percentages of patients dispensed opioids within seven days (opioid rate), with 95% confidence intervals (CIs), stratified by hospital and opioid type, adjusted for length of stay, and for autocorrelation within hospital using generalized linear modeling. RESULTS: The opioid dispensation rate dropped from 31% (95% CI, 30 to 33) in 2004 to 16% (95% CI, 15 to 17) in 2016, where it remained through 2019. Five hospitals showed steep reductions from over 40% to under 10% within two to three years, but in most hospitals the opioid dispensation rate decreased slowly-11 had little reduction and three showed increases. Codeine dispensing dropped from 31% in 2004-2008 by 4% per year, while tramadol and hydromorphone dispensing rose. After 2015, rates were stable (hydromorphone, 8%; tramadol, 6%; codeine, 3%; and oxycodone, 0.5%). CONCLUSION: After Health Canada's 2008 warning against codeine use by breastfeeding mothers, post-CD opioid dispensing declined disjointedly across BC hospitals. Rates did not decrease further after the opioid overdose epidemic was declared a public health emergency in BC in 2016. The present study highlights opportunities for quality improvement and opioid stewardship through monitoring using administrative databases.

RéSUMé: OBJECTIF: Décrire la délivrance d'opioïdes après le congé après un accouchement par césarienne dans 49 hôpitaux de la Colombie-Britannique (C.-B.) et évaluer les occasions de régulation des opioïdes. MéTHODE: À l'aide de la base de données sur les congés des patients du ministère de la Santé de la Colombie-Britannique, nous avons relié 135 725 accouchements par césarienne réalisés en 2004-2016 et 30 919 accouchements par césarienne réalisés en 2017-2019 (durée de séjour ≤ quatre jours) en utilisant les numéros de carte santé personnels dépersonnalisés aux données sur les médicaments délivrés par toutes les pharmacies communautaires de la Colombie-Britannique (PharmaNet). Nous avons exclu les patientes atteintes de cancer et celles à qui des opioïdes avaient été délivrés l'année précédente. À l'aide d'une modélisation linéaire généralisée, nous avons mesuré les tendances en pourcentages annuels de patientes ayant reçu des opioïdes dans les sept jours (taux d'opioïdes), avec des intervalles de confiance (IC) à 95 %, stratifiés par hôpital et par type d'opioïdes, ajustés en fonction de la durée de séjour et des autocorrélations entre des taux de chaque hôpital. RéSULTATS: Le taux de délivrance d'opioïdes est passé de 31 % (IC 95 %, 30 à 33) en 2004 à 16 % (IC 95 %, 15 à 17) en 2016, où il est resté jusqu'en 2019. Cinq hôpitaux ont montré des réductions importantes, passant de plus de 40 % à moins de 10 % en deux à trois ans, mais dans la plupart des hôpitaux, le taux de délivrance d'opioïdes a diminué lentement ­ 11 ont affiché une faible réduction et trois ont montré des augmentations. La délivrance de codéine a diminué de 4 % par année, à partir de 31 % en 2004-2008, tandis que la délivrance de tramadol et d'hydromorphone a augmenté. Après 2015, les taux étaient stables (hydromorphone, 8 %; tramadol, 6 %; codéine, 3 %; et oxycodone, 0,5 %). CONCLUSION: Suite à la mise en garde de Santé Canada en 2008 contre la consommation de codéine par les mères qui allaitent, la délivrance d'opioïdes post-césarienne a diminué de façon inconstante dans les hôpitaux de Colombie-Britannique. Les taux n'ont pas diminué davantage après que l'épidémie de surdose d'opioïdes a été déclarée urgence de santé publique en Colombie-Britannique en 2016. La présente étude met en évidence les possibilités d'amélioration de la qualité et de régulation des opioïdes en procédant à une surveillance via les bases de données administratives.

Development and internal validation of a multivariable risk prediction model for severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block.

BACKGROUND: Rebound pain occurs after up to 50% of ambulatory surgeries involving regional anaesthesia. To assist with risk stratification, we developed a model to predict severe rebound pain after foot and ankle surgery involving single-shot popliteal sciatic nerve block. METHODS: After ethics approval, we performed a single-centre retrospective cohort study. Patients undergoing lower limb surgery with popliteal sciatic nerve block from January 2016 to November 2019 were included. Exclusion criteria were uncontrolled pain in the PACU, use of a perineural catheter, or loss to follow-up. We developed and internally validated a multivariable logistic regression model for severe rebound pain, defined as transition from well-controlled pain in the PACU (numerical rating scale [NRS] 3 or less) to severe pain (NRS ≥7) within 48 h. A priori predictors were age, sex, surgery type, planned admission, local anaesthetic type, dexamethasone use, and intraoperative anaesthesia type. Model performance was evaluated using area under the receiver operating characteristic curve (AUROC), Nagelkerke's R2, scaled Brier score, and calibration slope. RESULTS: The cohort included 1365 patients (mean [standard deviation] age: 50 [16] yr). The primary outcome was abstracted in 1311 (96%) patients, with severe rebound pain in 652 (50%). Internal validation revealed poor model performance, with AUROC 0.632 (95% confidence interval [CI]: 0.602-0.661; bootstrap optimisation 0.021), Nagelkerke's R2 0.063, and scaled Brier score 0.047. Calibration slope was 0.832 (95% CI: 0.623-1.041). CONCLUSIONS: We show that a multivariable risk prediction model developed using routinely collected clinical data had poor predictive performance for severe rebound pain after foot and ankle surgery. Prospective studies involving other patient-related predictors are needed. CLINICAL TRIAL REGISTRATION: NCT05018104.

Noise in the operating room during induction of anesthesia: impact of a quality improvement initiative.

PURPOSE: Noise in the operating room (OR) is common and associated with negative effects on anesthesiologists, surgeons, and patient outcomes. Induction of anesthesia is among the loudest perioperative periods. Despite its critical nature, there is little data on noise levels during induction, associated patient and anesthesiologist satisfaction, and the effects of noise reduction strategies. METHODS: We conducted a two-part prospective interventional quality improvement project on the care of adult patients receiving general anesthesia for elective noncardiac surgery. For part A, we measured average and peak noise (dB[A]) levels during anesthesia induction in N = 100 cases and administered a satisfaction questionnaire to anesthesiologists. We then applied a multidisciplinary educational program to OR personnel on active noise reduction strategies and subsequently collected data during N = 109 cases in a post-intervention phase. For part B, we administered satisfaction questionnaires to N = 100 patients pre- vs postintervention, respectively. RESULTS: Median [interquartile range] noise levels throughout induction were 66.0 [62.5-68.6] dB(A) preintervention vs 63.5 [60.1-65.4] dB[A] post-intervention (Hodges-Lehmann estimator of the difference, - 2.7 dB[A]; 95% confidence interval [CI], - 4.0 to - 1.5; P < 0.001). Peak noise levels during induction were 87.3 [84.0-90.5] dB(A) preintervention and 86.2 [81.8-89.3] dB(A) postintervention (Hodges-Lehmann estimator of the difference, - 1.8 dB[A]; 95% CI, - 3.3 to - 0.3; P = 0.02). Noise-related anesthesiologist satisfaction postintervention was significantly improved in multiple domains, including assessment of noise having distracted anesthesiologists. Patient satisfaction was high pre-intervention and did not significantly improve further. CONCLUSION: In this quality improvement project, average noise levels during induction of anesthesia, anesthesiologist satisfaction, and anesthesiologists' perceived ability to perform were improved following a multidisciplinary educational program on noise reduction in the OR. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT04204785); registered 19 December 2019.

RéSUMé: OBJECTIF: Le bruit en salle d'opération (SOP) est fréquent et associé à des effets négatifs sur les anesthésiologistes, les chirurgiens et les issues des patients. L'induction de l'anesthésie est l'une des périodes périopératoires les plus bruyantes. Malgré sa nature critique, il existe peu de données sur les niveaux sonores pendant l'induction, la satisfaction des patients et des anesthésiologistes qui y est reliée, et les effets des stratégies de réduction du bruit. MéTHODE: Nous avons mené un projet prospectif et interventionnel, en deux parties, d'amélioration de la qualité sur les soins aux patients adultes recevant une anesthésie générale pour une chirurgie non cardiaque non urgente. Dans le cadre de la première partie A, nous avons mesuré les niveaux de bruit moyen et maximaux (dB[A]) pendant l'induction de l'anesthésie dans n = 100 cas et administré un questionnaire de satisfaction aux anesthésiologistes. Nous avons ensuite appliqué un programme de formation multidisciplinaire au personnel de la salle d'opération sur les stratégies de réduction active du bruit et avons ensuite recueilli des données pour n = 109 cas dans une phase post-intervention. Pour la deuxième partie B, nous avons administré des questionnaires de satisfaction à n = 100 patients pré- vs post-intervention, respectivement. RéSULTATS: Les niveaux de bruit médians [écart interquartile] tout au long de l'induction étaient de 66,0 [62,5­68,6] dB(A) avant l'intervention vs 63,5 [60,1­65,4] dB[A] après l'intervention (estimateur de Hodges-Lehmann, − 2,7 dB[A]; intervalle de confiance [IC] 95 %, − 4,0 à − 1,5; P < 0,001). Les niveaux maximaux de bruit pendant l'induction étaient de 87,3 [84,0­90,5] dB(A) avant l'intervention et de 86,2 [81,8­89,3] dB(A) après l'intervention (estimateur de Hodges-Lehmann, − 1,8 dB[A]; IC 95 %, − 3,3 à − 0,3; P = 0,02). La satisfaction des anesthésiologistes par rapport au bruit après l'intervention a été considérablement améliorée dans de nombreux domaines, y compris l'évaluation du bruit ayant distrait les anesthésiologistes. La satisfaction des patients était élevée avant l'intervention et ne s'est pas améliorée de manière significative. CONCLUSION: Dans ce projet d'amélioration de la qualité, les niveaux de bruit moyens lors de l'induction de l'anesthésie, la satisfaction des anesthésiologistes et la capacité perçue des anesthésiologistes à réaliser leurs tâches ont été améliorés à la suite d'un programme de formation multidisciplinaire sur la réduction du bruit en salle d'opération. ENREGISTREMENT DE L'éTUDE: www.ClinicalTrials.gov (NCT04204785); enregistrée le 19 décembre 2019.

A Single Prophylactic Dose of Ondansetron Given at Cessation of Postoperative Propofol Sedation Decreases Postoperative Nausea and Vomiting in Cardiac Surgery Patients: A Randomized Controlled Trial.

BACKGROUND: Postoperative nausea and vomiting (PONV) is a common occurrence after cardiac surgery. However, in contrast to other surgical populations, routine PONV prophylaxis is not a standard of care in cardiac surgery. We hypothesized that routine administration of a single prophylactic dose of ondansetron (4 mg) at the time of stopping postoperative propofol sedation before extubation in the cardiac surgery intensive care unit would decrease the incidence of PONV. METHODS: With institutional human ethics board approval and written informed consent, we conducted a randomized controlled trial in patients ≥19 years of age with no history of PONV undergoing elective or urgent cardiac surgery procedures requiring cardiopulmonary bypass. The primary outcome was the incidence of PONV in the first 24 hours postextubation, compared by the χ test. Secondary outcomes included the incidence and times to first dose of rescue antiemetic treatment administration, the incidence of headaches, and the incidence of ventricular arrhythmias. RESULTS: PONV within the first 24 hours postextubation occurred in 33 of 77 patients (43%) in the ondansetron group versus 50 of 82 patients (61%) in the placebo group (relative risk, 0.70 [95% confidence interval {CI}, 0.51-0.95]; absolute risk difference, -18% [95% CI, -33 to -2]; number needed to treat, 5.5 [95% CI, 3.0-58.4]; χ test, P = .022). Kaplan-Meier "survival" analysis of the times to first rescue antiemetic treatment administration over 24 hours indicated that patients in the ondansetron group fared better than those in the placebo group (log-rank [Mantel-Cox] test; P = .028). Overall, 32 of 77 patients (42%) in the ondansetron group received rescue antiemetic treatment over the first 24 hours postextubation versus 47 of 82 patients (57%) in the placebo group (relative risk, 0.73 [95% CI, 0.52-1.00]; absolute risk difference, -16% [95% CI, -31 to 1]); P = .047. There were no significant differences between the groups in the incidence of postoperative headache (ondansetron group, 5 of 77 patients [6%] versus placebo group, 4 of 82 patients [5%]; Fisher exact test; P = .740) or ventricular arrhythmias (ondansetron group, 2 of 77 patients [3%] versus placebo group, 4 of 82 patients [5%]; P = .68). CONCLUSIONS: These findings support the routine administration of ondansetron prophylaxis at the time of discontinuation of postoperative propofol sedation before extubation in patients following cardiac surgery. Further research is warranted to optimize PONV prophylaxis in cardiac surgery patients.

Lung injury after asphyxia and hemorrhagic shock in newborn piglets: Analysis of structural and inflammatory changes.

OBJECTIVE: Asphyxia of newborns is a severe and frequent challenge of the peri- and postnatal period. The purpose of this study was to study early morphological, immunological and structural alterations in lung tissue after asphyxia and hemorrhage (AH). METHODS: 44 neonatal piglets (age 32 hrs) underwent asphyxia and hemorrhage (AH) and were treated according to the international liaison committee of resuscitation (ILCOR) guidelines. For this study, 15 piglets (blood transfusion (RBC) n = 9; NaCl n = 6, mean age 31 hrs) were randomly picked. 4 hours after ROSC (return of spontaneous circulation), lung tissue and blood samples were collected. RESULTS: An elevation of myeloperoxidase (MPO) activity was observed 4 hrs after AH accompanied by an increase of surfactant D after RBC treatment. After AH tight junction proteins Claudin 18 and junctional adhesion molecule 1 (JAM1) were down-regulated, whereas Occludin was increased. Furthermore, after AH and RBC treatment dephosphorylated active form of Connexin 43 was increased. CONCLUSIONS: AH in neonatal pigs is associated with early lung injury, inflammation and alterations of tight junctions (Claudin, Occludin, JAM-1) and gap junctions (Connexin 43) in lung tissue, which contributes to the development of lung edema and impaired function.

The Correlation of Prostate Volume and Prostate-specific Antigen Levels With Positive Bacterial Prostate Tissue Cultures.

OBJECTIVE: To compare prostate volume and prostate-specific antigen (PSA) levels with bacterial growth in prostate tissue cultures. MATERIALS AND METHODS: Fifty male patients who underwent transurethral prostate resection were investigated prospectively. Resection chips from the prostate gland were added to brain-heart infusion medium and incubated. PSA levels were determined preoperatively at our urology ward. The prostate gland volume was estimated by transabdominal ultrasound examination preoperatively. RESULTS: Persons with positive bacterial prostate tissue cultures have a greater prostate volume. This is significant in patients with and without histopathologic signs of prostatitis. Persons with positive bacterial prostate tissue cultures have higher PSA values. This is significant in patients without histopathologic signs of prostatitis. CONCLUSION: People with positive bacterial prostatic tissue culture have a higher prostate volume in comparison with patients with negative culture findings and show a tendency toward increased PSA levels as well.

The Role of Troponin in Blunt Cardiac Injury After Multiple Trauma in Humans.

BACKGROUND: The incidence of cardiac injury in immediate fatalities after blunt trauma remains underestimated, and reliable diagnostic strategies are still missing. Furthermore, clinical data concerning heart-specific troponin serum levels, injury severity score (ISS), catecholamine treatment and survival of patients on admission to the hospital have rarely been interrelated so far. Therefore, the object of the present study was to identify predictive parameters for mortality in the context of blunt cardiac injury. METHODS: This retrospective observational study included 173 severely injured patients with an ISS ≥25 admitted to the University Hospital of Ulm, a level 1 trauma center, during 2009-2013 . Furthermore, 83 blunt trauma victims who died before hospital admission were subjected to postmortem examination at the Institute of Legal Medicine, University of Ulm, during 2009-2014. ISS, cardiac injury and associated thoracic injuries were determined in both groups. Furthermore, in the hospitalized patients, serum troponin and IL-6 levels were measured. RESULTS: Macroscopic heart injury was observed in 18 % of the patients who died at the scene and only in 1 % of the patients admitted to the hospital, indicating that macroscopic heart injury is associated with an immediate life-threatening condition. Troponin levels were elevated in 43 % of the patients after admission to the hospital. Moreover, troponin serum concentrations were significantly higher in patients treated with norepinephrine (26.4 ± 4 ng/l) and in non-survivors (84.9 ± 22.8 ng/l) compared to patients without catecholamines and survivors, respectively. CONCLUSIONS: Macroscopic heart injury was 20 times more frequent in non-survivors than in survivors. Serum troponin levels correlated with mortality after multiple injury and therefore may represent a valuable prognostic marker in trauma patients.

Effect of Nerve Stimulation Use on the Success Rate of Ultrasound-Guided Subsartorial Saphenous Nerve Block: A Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Ultrasound-guided subsartorial saphenous nerve block is commonly used to provide complete surgical anesthesia of the foot and ankle in combination with a popliteal sciatic nerve block. However, in part owing to its small caliber and absence of a prominent vascular landmark in the subsartorial plane distal to the adductor canal, the saphenous nerve is more difficult to reliably block than the sciatic nerve in the popliteal fossa. Although the saphenous nerve is a sensory nerve only, neurostimulation can be used to elicit a "tapping" sensation on the anteromedial aspect of the lower leg extending toward the medial malleolus. Our objective was to test the hypothesis that the addition of nerve stimulation use to an ultrasound (US)-guided technique will increase the success rate of subsartorial saphenous nerve block. METHODS: With institutional human ethics board approval and participants' written informed consent, we enrolled 80 patients undergoing foot and ankle surgery in a randomized, single-blinded, parallel-group clinical trial. Patients were randomly assigned to receive US-guided subsartorial saphenous nerve block either alone (US group) or with the use of additional nerve stimulation (NS group; time limit, 5 minutes). For saphenous nerve blockade, all patients received 10 mL of 0.5% ropivacaine. The primary end point was complete absence of sensation to pinprick at 30 minutes at two different anatomic areas in the distribution of the saphenous nerve (2 cm proximal to the medial malleolus and 10 cm distal to the medial tibial condyle). Secondary end points included decreased sensation at 30 minutes and block failure (normal sensation) at 30 minutes. This trial was registered at ClinicalTrials.gov: NCT02382744. RESULTS: All 80 patients completed the trial (40 patients in each group). Twenty-two patients (55%) in the NS group versus 18 (45%) in the US group had complete absence of sensation to pinprick at 30 minutes at both anatomic areas of assessment (Fisher exact test, P = 0.25 [one sided]; 95% confidence interval of difference in proportions, -11.9% to 31.9%). The percentages of patients with any evidence of block (decreased or complete absence of sensation) at both areas at 30 minutes were 92.5% (NS) and 97.5% (US), respectively (P = 0.62 [two sided]); corresponding failure rates (normal sensation) were 7.5% (NS) and 2.5% (US). In the NS group, no response in the saphenous nerve distribution was elicited within 5 minutes of stimulation time limit in 20% of patients (n = 8). All of the patients in the NS group with normal sensation at 30 minutes (n = 3) were among this subcohort. CONCLUSIONS: The addition of the use of nerve stimulation did not improve the success rate of US-guided subsartorial saphenous nerve block. However, in the NS group, an inability to elicit a "tapping" sensation in the saphenous nerve distribution was associated with block failure.

Problems and pitfalls in grading of bone marrow fibrosis, collagen deposition and osteosclerosis - a consensus-based study.

AIMS: In the era of potentially disease-modifying agents such as Janus kinase inhibitors, accurate grading and differentiation of bone marrow (BM) fibrosis has become more relevant to assess staging of disease and therapeutic effects. However, different fibrosis grading models have been used in the past without uniformity, including the proposal by the World Health Organization. Current scoring systems are based only on reticulin fibrosis. Therefore, additional assessment of collagen and the grade of osteosclerosis appear to be essential to discriminate all components of the complex BM fibrous matrix. METHODS AND RESULTS: We evaluated problems and pitfalls regarding staining techniques and the interpretation of reticulin fibrosis on a total of 352 samples. Furthermore, we propose a minor modification of the current grading and separate scoring for collagen deposition and osteosclerosis. Reproducibility of gradings was tested among 11 haematopathologists in a blinded assessment. Overall, the inter-rater reliability of all three grading systems ranged between 0.898 and 0.926. CONCLUSIONS: A standardized assessment of BM fibrosis with differentiation between reticulin, collagen and osteosclerosis is recommended to evaluate the various components of the fibrous matrix which may be delinked after therapy. In this regard, quality of staining and application of laboratory standards enable a highly reproducible scoring.

Regional Versus General Anesthesia and the Incidence of Unplanned Health Care Resource Utilization for Postoperative Pain After Wrist Fracture Surgery: Results From a Retrospective Quality Improvement Project.

BACKGROUND AND OBJECTIVES: The establishment at our center of a dedicated regional anesthesia service in 2008-2009 has resulted in a marked increase in single-shot brachial plexus blocks (sBPBs) for ambulatory wrist fracture surgery. Despite the documented benefits of regional over general anesthesia (GA), there has been a perceived increase among sBPB patients in postoperative return rates for pain at our institution. We conducted a retrospective quality improvement project to examine this. METHODS: After exemption from human ethics board review, we sought to identify and contact all wrist fracture surgery patients treated at our center between 2003 and 2012. Our primary outcome was the incidence of unplanned physician visits (office/clinic or emergency department) for pain in the first 48 hours after surgery. Other main outcomes included the incidence of seeking any form of medical attention for pain and self-reporting of severe pain in the first 48 hours. RESULTS: Of 1008 identified patients, 419 could be contacted; 195 qualified for analysis. The incidence of unplanned physician visits in the first 48 hours was 12% (13 of 118) among sBPB patients versus 4% (3 of 77) in GA patients (odds ratio [OR], 3.1; 95% confidence interval [95% CI], 0.8-11.1; P = 0.11). More sBPB versus GA patients sought any form of medical attention for pain (20% vs 5%; OR, 4.7; 95% CI, 1.4-10.9; P = 0.003). Similarly, more sBPB patients reported severe postoperative pain (41% vs 10%; OR, 5.9; 95% CI, 2.6-13.4; P < 0.0001). CONCLUSIONS: Patients who received sBPBs for ambulatory wrist fracture surgery had a higher rate of unplanned health care resource utilization caused by pain after hospital discharge than those undergoing GA. These findings warrant confirmation in a prospective trial and emphasize the need for a defined postdischarge analgesic pathway as well as the potential merits of perineural home catheters.

Prevalence, clinical characteristics, and prognosis of GATA2-related myelodysplastic syndromes in children and adolescents.

Germline GATA2 mutations cause cellular deficiencies with high propensity for myeloid disease. We investigated 426 children and adolescents with primary myelodysplastic syndrome (MDS) and 82 cases with secondary MDS enrolled in 2 consecutive prospective studies of the European Working Group of MDS in Childhood (EWOG-MDS) conducted in Germany over a period of 15 years. Germline GATA2 mutations accounted for 15% of advanced and 7% of all primary MDS cases, but were absent in children with MDS secondary to therapy or acquired aplastic anemia. Mutation carriers were older at diagnosis and more likely to present with monosomy 7 and advanced disease compared with wild-type cases. For stratified analysis according to karyotype, 108 additional primary MDS patients registered with EWOG-MDS were studied. Overall, we identified 57 MDS patients with germline GATA2 mutations. GATA2 mutations were highly prevalent among patients with monosomy 7 (37%, all ages) reaching its peak in adolescence (72% of adolescents with monosomy 7). Unexpectedly, monocytosis was more frequent in GATA2-mutated patients. However, when adjusted for the selection bias from monosomy 7, mutational status had no effect on the hematologic phenotype. Finally, overall survival and outcome of hematopoietic stem cell transplantation (HSCT) were not influenced by mutational status. This study identifies GATA2 mutations as the most common germline defect predisposing to pediatric MDS with a very high prevalence in adolescents with monosomy 7. GATA2 mutations do not confer poor prognosis in childhood MDS. However, the high risk for progression to advanced disease must guide decision-making toward timely HSCT.

Incidence of and Risk Factors for Delirium After Cardiac Surgery at a Quaternary Care Center: A Retrospective Cohort Study.

OBJECTIVE: Delirium after cardiac surgery is associated with persistent cognitive deficits and increased mortality. The authors' objective was to determine the incidence of and risk factors for delirium in a mixed cohort of patients undergoing on-pump and off-pump cardiac surgery and transcatheter aortic valve implantations (TAVI) in a Canadian quaternary care center. This study followed a pilot from the same center on patients treated in 2007. DESIGN: A retrospective cohort study. SETTING: A quaternary care center in Vancouver, B.C., Canada. PARTICIPANTS: Patients undergoing cardiopulmonary bypass grafts (CABG), conventional valve replacements, combined CABG-valve replacements, transfemoral TAVI, or transapical TAVI in 2008. INTERVENTIONS: Data from 679 charts on demographics, medical history, medications, laboratory results, surgical procedure, and anesthesia were abstracted and analyzed using univariate and multivariate analyses. Nurses screened for delirium using the Confusion Assessment Method, and the final diagnoses were made clinically by physicians. Risk factors were identified using logistic regression and bootstrapping. MEASUREMENTS AND MAIN RESULTS: Delirium occurred in 28% of patients. Delirium was most common in transapical TAVI (47%), and least common in transfemoral TAVI (17%). Delirious patients were older and had greater preoperative cardiac and neurologic burdens than nondelirious patients. Age≥64 years, history of delirium, history of stroke/transient ischemic attack, cognitive impairment, depression, and preoperative use of beta-blocker(s) were associated independently with delirium. CONCLUSIONS: The incidence of delirium varied greatly with the type of procedure. The authors' logistic regression model showed that age and certain pre-existing neurologic conditions could predict delirium after cardiac surgery.

Ultrasound guidance versus direct palpation for radial artery catheterization by expert operators: a randomized trial among Canadian cardiac anesthesiologists.

PURPOSE: The use of ultrasound (US) for radial arterial catheterization has been reported to result in faster insertion times with fewer complications when compared with traditional direct palpation (DP). We sought to determine if this applies to expert operators and tested the hypothesis that, among cardiac anesthesiologists, US-guided insertion similarly results in faster insertion times as well as fewer re-directs, attempts, and complications. METHODS: Following Research Ethics Board Approval, we conducted a randomized clinical trial in 125 patients scheduled for cardiac surgery at a single tertiary/quaternary care centre. Patients were randomized to either US- or DP-guided radial artery catheterization by attending cardiac anesthesiologists. The primary endpoint was time to catheter placement. Secondary endpoints included the number of attempts and re-directs as well as the failure rate. RESULTS: There were no differences between the DP- (n = 62) vs US-guided (n = 63) groups in median [interquartile range] time to placement (104 [76-212] sec vs 104 [68-270] sec, respectively; P = 0.66), number of re-directs (2 [0-6] vs 3 [1-5], respectively; P = 0.82), or number of attempts (1 [1-2] vs 1 [1-2], respectively; P = 0.08). The first-attempt success rate was 56.4% in the DP group and 71.4 % in the US group (P = 0.10). Failure rate and hematoma rate in the DP group were 21.0% and 22.6%, respectively, compared with 12.7% and 11.1% in the US group (P = 0.24 and 0.10, respectively). CONCLUSIONS: Among experienced cardiac anesthesiologists, the use of US to facilitate radial arterial catheterization did not affect insertion times, the number of re-directs, or the number of attempts when compared with DP. Ultrasound use had no significant effects on the rates of success on first attempt, failure, or hematoma formation. This trial was registered at www.clinicaltrials.gov : NCT02118441.

Hemidiaphragmatic paralysis following ultrasound-guided supraclavicular versus infraclavicular brachial plexus blockade: a randomized clinical trial.

BACKGROUND AND OBJECTIVES: The comparative incidences of hemidiaphragmatic paralysis associated with contemporary ultrasound-guided supraclavicular versus infraclavicular blockade have not received extensive study. We tested the hypothesis that the infraclavicular approach results in a lower incidence of hemidiaphragmatic paralysis compared with supraclavicular blockade when a standard local anesthetic volume and concentration are used. METHODS: With institutional human ethics board approval, we enrolled 64 patients undergoing right-sided upper extremity surgery in a randomized, blinded, parallel-group trial. Patients were assigned to ultrasound-guided supraclavicular or infraclavicular blockade with 30 mL of 0.5% ropivacaine. The primary end point was complete hemidiaphragmatic paralysis at 30 minutes, defined as a greater than 75% reduction in diaphragmatic excursion measured with the voluntary sniff test using M-mode ultrasonography. Partial paralysis was defined as a 25% to 75% reduction. RESULTS: Eleven (34%) of 32 patients in the supraclavicular group versus 1 (3%) of 32 in the infraclavicular group had complete hemidiaphragmatic paralysis (P = 0.001 [1-tailed]; relative risk, 11.0 [95% confidence interval, 1.5-80.3]); 44% versus 13% had any (complete or partial) paralysis (P = 0.006; relative risk, 3.5 [95% confidence interval, 1.3-9.5]). Eight (25%) of 32 patients in the supraclavicular group versus 5 (16%) of 32 in the infraclavicular group reported dyspnea (P = 0.54). CONCLUSIONS: Ultrasound-guided supraclavicular blockade with 30 mL of 0.5% ropivacaine produced complete hemidiaphragmatic paralysis in approximately one-third of patients. The infraclavicular approach greatly reduced this risk but did not eliminate it. These data may aid in the selection of the approach to brachial plexus blockade, particularly in ambulatory patients and/or those with respiratory comorbidities.

Incidence and risk factors for impaired mobility in older cardiac surgery patients during the early postoperative period.

AIM: Mobility issues in the early postoperative period result in poor functional outcomes and diminished quality of life for patients of advanced age. We determined the incidence of and risk factors for mobility issues in the early postoperative period in patients receiving open heart cardiac surgery. METHODS: A retrospective chart review was carried out on 396 patients receiving open heart coronary artery bypass grafts (CABG), valve replacements and combination CABG-valve replacements in a tertiary care hospital. Data on demographics, comorbidities, laboratory values, medications, anesthesia and postoperative care were abstracted. Mobility issues were considered present if they were documented in the medical chart. All pre- and intraoperative variables were entered into logistic regression. RESULTS: The mean age was 66.4 ± 11.9 years. In a subset of patients aged 75 years and older, the mean age was 79.8 ± 3.7 years. Mobility issues affected 36.9% of individuals from the total sample, and 47.6% of older patients. Increased age was a weak predictor in the total sample (OR 1.03), but was the only predictor in older adults (OR 1.1). The strongest predictors in the total sample were preoperative COPD (OR 2.7), congestive heart failure (CHF; OR 2.1), renal disease (OR 1.9), and pre-existing physical impairment (OR 1.8). Older patients with mobility issues were more likely to be discharged to acute care facilities, and had higher rates of mortality 3 years after surgery. CONCLUSIONS: Over one-third of cardiac surgery patients experienced early postoperative mobility issues. Older patients and those with COPD, CHF, renal disease or pre-existing physical impairments might benefit from preoperative consultation with physical therapists.

Ultrasound-guided saphenous nerve block--within versus distal to the adductor canal: a proof-of-principle randomized trial.

PURPOSE: Reliable saphenous nerve blockade is a desirable complement to popliteal sciatic nerve blockade for foot and ankle surgery. We compared two promising ultrasound-guided techniques, the supine adductor canal (AC) technique and the prone peri-saphenous branch of the descending genicular artery (Peri-SBDGA) technique, using 8 mL of 2% lidocaine with epinephrine 1:400,000. METHODS: Following Research Ethics Board approval, we conducted a randomized single-blinded parallel-group trial in 102 patients undergoing foot and ankle surgery at a single centre. The primary endpoint was saphenous nerve ease of visualization (0 = not visible; 1 = visible with difficulty; and 2 = easily visible). Other endpoints included vascular landmark visualization (0 = not visible; 1= visible with colour flow Doppler; 2 = visible without colour flow Doppler), block success, onset, and complications. RESULTS: Ninety-one patients were eligible for analysis. Saphenous nerve visibility was not different between the groups (visibility score = 2: AC group, n = 24/49 [49%] vs Peri-SBDGA group, 20/42 [48%]; P = 1.00). Vascular landmark visibility was better in the AC group than in the Peri-SBDGA group (visibility score = 2: 41/49 [84%] vs 25/42 [60%], respectively; P = 0.018). Block success rates were similar (AC group, 41/49 [84%] vs Peri-SBDGA group, 34/42 [81%]; P = 0.79), as were median [interquartile range] onset times (AC group, 5 [5-10] min vs Peri-SBDGA group, 8 [5-11] min; P = 0.38). CONCLUSION: In this randomized trial, we found no differences in nerve visibility, block success rate, or onset between the AC and Peri-SBDGA techniques of ultrasound-guided saphenous nerve blockade, although the former technique provided superior vascular landmark visibility. Neither technique produced a sufficiently high success rate to provide reliable surgical anesthesia per se.