Analgesic duration of interscalene block after outpatient arthroscopic shoulder surgery with intravenous dexamethasone, intravenous dexmedetomidine, or their combination: a randomized-controlled trial.

PURPOSE: Both intravenous dexamethasone and dexmedetomidine prolong the analgesic duration of interscalene blocks (ISB) after arthroscopic shoulder surgery. This study compared their relative effectiveness and the benefit of their use in combination. METHODS: This single-centre, double-blinded, parallel three-group superiority trial randomized 198 adult patients undergoing ambulatory arthroscopic shoulder surgery. Patients received preoperative ISB with 30 mL 0.5% bupivacaine and 50 µg dexmedetomidine or 4 mg dexamethasone or both of these agents as intravenous adjuncts. The primary outcome was analgesic block duration. Secondary outcomes included the quality of recovery 15 score (range: 0-150) on day 1 and postoperative neurologic symptoms in the surgical arm. RESULTS: Block durations (n = 195) with dexamethasone (median [range], 24.5 [2.0-339.5] hr) and both adjuncts (24.0 [1.5-157.0] hr) were prolonged compared with dexmedetomidine (16.0 [1.5-154.0] hr). When analyzed by linear regression after an unplanned log transformation because of right-skewed data, the corresponding prolongations of block duration were 59% (95% confidence interval [CI], 28 to 97) and 46% (95% CI, 18 to 80), respectively (both P < 0.001). The combined adjuncts were not superior to dexamethasone alone (-8%; 95% CI, -26 to 14; P = 0.42). Median [IQR] quality of recovery 15 scores (n = 197) were significantly different only between dexamethasone (126 [79-149]) and dexmedetomidine (118.5 [41-150], P = 0.004), but by an amount less than the 8-point minimum clinically important difference. CONCLUSION: Dexamethasone is superior to dexmedetomidine as an intravenous adjunct for prolongation of bupivacaine-based ISB analgesic duration. There was no additional benefit to using both adjuncts in combination. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03270033); registered 1 September 2017.

RéSUMé: OBJECTIF: La dexaméthasone et la dexmédétomidine intraveineuses prolongent toutes deux la durée analgésique des blocs interscaléniques (BIS) après une chirurgie arthroscopique de l'épaule. Cette étude a comparé leur efficacité relative et les avantages d'une utilisation des deux agents en combinaison. MéTHODE: Cette étude de supériorité monocentrique en trois groupes parallèles à double insu a randomisé 198 patients adultes subissant une chirurgie arthroscopique de l'épaule en ambulatoire. Les patients ont reçu un BIS préopératoire composé de 30 mL de bupivacaïne 0,5 % avec 50 µg de dexmédétomidine, 4 mg de dexaméthasone, ou la combinaison de ces deux agents comme adjuvants intraveineux. Le critère d'évaluation principal était la durée analgésique du bloc. Les critères d'évaluation secondaires comprenaient le score de qualité de récupération (QoR) 15 (plage : 0-150) au jour 1 et les symptômes neurologiques postopératoires dans le bras opéré. RéSULTATS: Les durées des blocs (n = 195) avec la dexaméthasone (médiane [plage], 24,5 [2,0-339,5] heures) et la combinaison des deux adjuvants (24,0 [1,5-157,0] heures) ont été prolongées par rapport à la dexmédétomidine (16,0 [1,5-154,0] heures). Lorsqu'elles ont été analysées par régression linéaire après une transformation logarithmique non planifiée en raison de données biaisées vers la droite, les prolongations correspondantes de la durée du bloc étaient de 59 % (intervalle de confiance [IC] 95 %, 28 à 97) et de 46 % (IC 95 %, 18 à 80), respectivement (les deux P < 0,001). La combinaison des adjuvants n'était pas supérieure à la dexaméthasone seule (-8 %; IC 95 %, -26 à 14; P = 0,42). Les scores médians [ÉIQ] de qualité de récupération 15 (n = 197) n'étaient significativement différents qu'entre la dexaméthasone (126 [79-149]) et la dexmédétomidine (118,5 [41-150], P = 0,004), mais la différence observée était inférieure à la différence minimale de 8 points nécessaire pour être considérée cliniquement importante. CONCLUSION: La dexaméthasone est supérieure à la dexmédétomidine en tant qu'adjuvant intraveineux pour prolonger la durée analgésique d'un BIS à base de bupivacaïne. Aucun avantage supplémentaire n'a été observé lors de l'utilisation combinée des deux adjuvants. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03270033); enregistrée le 1er septembre 2017.

Effect of dexamethasone dose and route on the duration of interscalene brachial plexus block for outpatient arthroscopic shoulder surgery: a randomized controlled trial.

PURPOSE: Dexamethasone prolongs the duration of interscalene block, but the benefits of higher doses and perineural vs intravenous administration remain unclear. METHODS: This factorial design, double-blinded trial randomized 280 adult patients undergoing ambulatory arthroscopic shoulder surgery at a single centre in a 1:1:1:1 ratio. Patients received ultrasound-guided interscalene block with 30 mL 0.5% bupivacaine and 4 mg or 8 mg dexamethasone by either the perineural or intravenous route. The primary outcome (block duration measured as the time of first pain at the surgical site) and secondary outcomes (adverse effects, postoperative neurologic symptoms) were assessed by telephone. In this superiority trial, the predetermined minimum clinically important difference for comparisons between doses and routes was 3.0 hr. RESULTS: The perineural route significantly prolonged the mean block duration by 2.0 hr (95% confidence interval [CI], 0.4 to 3.5 hr; P = 0.01), but 8 mg of dexamethasone did not significantly prolong the mean block duration compared with 4 mg (1.3 hr; 95% CI, -0.3 to 2.9 hr, P = 0.10), and there was no significant statistical interaction (P = 0.51). The mean (95% CI) block durations, in hours, were 24.0 (22.9 to 25.1), 24.8 (23.2 to 26.3), 25.4 (23.8 to 27.0), and 27.2 (25.2 to 29.3) for intravenous doses of 4 and 8 mg and perineural doses of 4 and 8 mg, respectively. There were no marked differences in side effects between groups. At 14 postoperative days, 57 (20.4%) patients reported neurologic symptoms, including dyspnea and hoarseness. At six months postoperatively, only six (2.1%) patients had residual symptoms, with four (1.4%) patients' symptoms unlikely related to interscalene block. CONCLUSION: Compared with the intravenous route, perineural dexamethasone prolongs the mean interscalene block duration by a small amount that may or may not be clinically significant, regardless of dose. However, the difference in mean block durations between 8 mg and 4 mg of dexamethasone is highly unlikely to be clinically important, regardless of the administration route. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT02426736). Registered 14 April 2015.

Cerebral oxygen desaturation during one-lung ventilation: correlation with hemodynamic variables.

PURPOSE: Cerebral desaturation occurs frequently in patients undergoing one-lung ventilation for thoracic surgery. The mechanism of this desaturation is unclear regarding its etiology. The objective of this study was to investigate whether or not decreases in cerebral oxygen saturation associated with one-lung ventilation were a consequence of decreased cardiac output. METHODS: A blinded observational study was conducted in 23 patients undergoing one-lung ventilation with thoracic surgery. Eighteen patients completed the study. Cerebral oxygen saturation was monitored using near-infrared spectroscopy (FORE-SIGHT(®) monitor). Invasive blood pressure was monitored and hemodynamic variables were interrogated using the FloTrac(®) system. Anesthesia was maintained with sevoflurane with a F(i)O(2) of 1.0. Post-hoc analysis involved a comparison between baseline and integrated changes in cerebral saturation, heart rate, stroke index, cardiac index, and stroke volume variability. RESULTS: All patients showed cerebral desaturation from a baseline of two-lung ventilation in the lateral decubitus position following institution of one-lung ventilation. The cardiac index was stable at these times, but with one-lung ventilation, the heart rate decreased and the stroke index increased to maintain a stable product. The integral of heart rate × time was inversely correlated with the integral of cerebral desaturation × time (linear regression analysis; P = 0.02; (df) = 16)). CONCLUSIONS: Cerebral oxygen desaturation was universal during one-lung ventilation in this study. There was no correlation between cerebral desaturation and cardiac output or other hemodynamic variables.

Postoperative neurological symptoms following arthroscopic shoulder surgery with interscalene block: an exploratory secondary analysis of pooled randomized controlled trial data.

OBJECTIVE: Postoperative neurological symptoms (PONS) are recognized complications of regional anesthesia and orthopedic surgery. We aimed to better characterize prevalence and potential risk factors in a homogeneous population of randomized, controlled trial participants. METHODS: Data were pooled from two randomized controlled trials of analgesia after interscalene block with perineural or intravenous adjuvants (NCT02426736, NCT03270033). Participants were at least 18 years of age and undergoing arthroscopic shoulder surgery at a single ambulatory surgical center. PONS were assessed by telephone follow-up at 14 days and 6 months postoperatively, and defined as patient report of numbness, weakness, or tingling in the surgical limb, alone or in combination, and regardless of severity or etiology. RESULTS: At 14 days, PONS occurred in 83 of 477 patients (17.4%). Among these 83 patients, 10 (12.0%) continued to have symptoms a half-year after surgery. In exploratory univariate analyses, no patient, surgical or anesthetic characteristics were significantly associated with 14-day PONS except for lower postoperative day 1 Quality of Recovery-15 questionnaire total score (OR 0.97 (95% CI, 0.96 to 0.99), p<0.01). This result was driven largely by the emotional domain question scores (OR 0.90 95% CI 0.85 to 0.96, p<0.001). Report of all three of numbness, weakness and tingling at 14 days vs other 14-day symptom combinations was associated with persistent PONS at 6 months (OR 11.5 95% CI 2.2 to 61.8, p<0.01). CONCLUSION: PONS are common after arthroscopic shoulder surgery performed with single injection ultrasound-guided interscalene blocks. No definitive mitigating risk factors were identified.

Demographic and clinical characteristics of free-text writers in chronic pain patient intake questionnaires.

BACKGROUND: Chronic pain is a prevalent and burdensome problem within the Canadian health care system, where the gold standard treatment occurs at multidisciplinary pain facilities. Patient intake questionnaires (PIQs) are standard practice for obtaining health information, with many patients including free-text (e.g., writing in margins of questionnaires) on their PIQs. AIMS: This study aims to quantitatively examine whether and how patients who include free-text on PIQs differ from those who do not. METHODS: We retrospectively analyzed 367 PIQs at a Canadian pain facility in Winnipeg, Canada. Patients were categorized into free-text (i.e., any text response not required in responding to questions) or no free-text groups. Groups were compared on sociodemographics, pain, health care utilization, and depressive symptoms with independent samples t-tests and chi-square analyses. RESULTS: Patients with free-text compared to those without had more sources of pain (6.66 vs. 4.63), longer duration of pain (123.2 months vs. 68.1 months), and a greater proportion of past pain conditions (66.3% vs. 55.2%). Additionally, they had tried more treatments for their pain, had seen more specialists, had tried more past medications, were currently on more medications, and had undergone more tests. No differences were identified for depressive symptoms across groups. CONCLUSIONS: This study is the first to examine patient and health-related correlates of free-text on PIQs at a Canadian pain facility. Results indicate that there are significant differences between groups on pain and health care utilization. Thus, patients using free-text may require additional supports and targeted interventions to improve patient-physician communication and patient outcomes.

Contexte: La douleur chronique est un problème répandu et pénible dans le système des soins de santé au Canada, où le traitement de référence se produit dans un centre multidisciplinaire de la douleur. Les formulaires d'admission du patient sont une pratique courante pour obtenir des renseignements sur la santé, et de nombreux patients y incluent du texte libre (en écrivant, par exemple, dans les marges du formulaire).Objectifs: Cette étude vise àexaminer quantitativement si et comment les patients qui incluent du texte libre sur leur formulaire d'admission diffèrent de ceux qui ne le font pas.Méthodes: Nous avons analysé rétrospectivement 367 formulaires d'admission dans un centre canadien de traitement de la douleur à Winnipeg, au Canada. Les patients ont été classés en deux groupes : avec texte libre (c'est-à-dire ayant inscrit une réponse sous forme de texte non requis au moment de répondre aux questions) ou sans texte libre. Les groupes ont été comparés en ce qui concerne les critères sociodémographiques, la douleur, l'utilisation des soins de santé et les symptômes dépressifs, à l'aide de tests t et chi carré pour échantillons indépendants.Résultats: Les patients avec texte libre par rapport à ceux sans texte libre avaient plus de sources de douleur (6,66 comparativement à 4,63), une plus longue durée de la douleur (123,2 mois comparativement à 68,1 mois) et une plus grande proportion de douleur par le passé (66,3 % comparativement à 55,2 %). De plus, ils avaient essayé d'autres traitements pour leur douleur, avaient vu plus de spécialistes, avaient essayé plus de médicaments par le passé, prenaient à ce moment plus de médicaments et avaient subi plus de tests. Aucune différence n'a été recensée pour les symptômes dépressifs entre les groupes.Conclusions: Cette étude est la première à examiner les corrélats liés au patient et à la santé de l'existence de texte libre sur les formulaires d'admission dans un centre de traitement de la douleur au Canada. Les résultats indiquent qu'il existe des différences importantes entre les groupes en ce qui concerne la douleur et l'utilisation des soins de santé. Ainsi, les patients utilisant le texte libre peuvent avoir besoin de soutien additionnel et d'interventions ciblées pour améliorer la communication patient-médecin et les résultats du patient.

Intrathecal catheter granuloma associated with isolated baclofen infusion.

Intrathecal (IT) baclofen is an effective management strategy for controlling spasticity in patients unresponsive to maximal oral therapy. We present the case of a 57-yr-old woman who was rendered quadriplegic after a complete spinal cord transection at the C6 level. Her course was complicated by severe spasms, which were uncontrolled despite titrating orally administered baclofen to 80 mg/d. IT baclofen testing was performed with good response, and administration was commenced via an implanted intrathecal pump 6 mo after the injury at an initial dose of 200 microg/d. Catheter revision was required 2 wk later as a result of catheter displacement. The initial IT baclofen dose was gradually increased to achieve good control at a level of 400 microg/d. After a period of stability lasting 38 mo, her lower limb spasms dramatically increased in severity and remained poorly controlled despite repeated dose increases. Contrast pumpogram and computed tomography myelogram were performed to exclude a mechanical cause for this apparent increase in baclofen requirement. These investigations revealed neither catheter displacement nor fracture as suspected but, rather, displayed the presence of a catheter tip-associated mass. Catheter tip granuloma has not previously been described in a patient receiving IT baclofen alone. This suggests that although uncommon, the possibility of catheter-associated granuloma must be considered in all patients receiving IT baclofen presenting with altered neurological function or significant increase in drug requirement.

Low-dose intrathecal morphine does not delay early extubation after cardiac surgery.

PURPOSE: This study was designed to examine the efficacy of low-dose intrathecal morphine (ITM) on extubation times and pain control after cardiac surgery. METHODS: 43 patients undergoing elective cardiac surgery were enrolled in this prospective, randomized, double-blind placebo controlled trial. Patients were given a pre-induction dose of ITM (6 microg x kg(-1) per ideal body weight in 5 mL normal saline, group ITM) or 5 mL of intrathecal normal saline (group ITS). Anesthesia was induced with thiopental (3 mg x kg(-1)), sufentanil, midazolam and rocuronium. The total allowable doses of sufentanil and midazolam for the entire case were limited to 0.5 microg x kg(-1) and 0.045 mg x kg(-1) respectively. Anesthesia was maintained with isoflurane before and during cardiopulmonary bypass (CPB), and with propofol after CPB. In the postanesthesia care unit, patients received nurse-administered morphine followed by patient-controlled analgesia morphine. Serial visual analogue scale pain scores, morphine use, mini-mental state examinations and pulmonary function tests were measured for 48 hr. Patient satisfaction questionnaires were completed at the time of discharge. RESULTS: Mean times to extubation from the application of dressings were short and did not differ between groups (ITM = 41.4 +/- 33.0 min, ITS = 39.2 +/- 37.1 min). During the first 24 hr postoperatively, the ITM group had improved pain control and a lower iv morphine requirement than the control group, both at rest and during deep breathing. Both forced expiratory volume in one second and forced vital capacity were improved in the ITM group. There were no differences in spinal-related side effects or in the overall complication rates. Patient satisfaction was high in both groups. CONCLUSION: Low-dose ITM for cardiac surgery did not delay early extubation, but it improved postoperative analgesia and pulmonary function.

Orthopedic injuries associated with backyard trampoline use in children.

INTRODUCTION: Trampolining on an outdoor oval or circular trampoline is a popular activity for children but is associated with a number of orthopedic injuries, especially in children between the ages of 5 and 15 years. In this paper we review the orthopedic injuries in children associated with backyard trampoline use, through our experience with a series of children admitted to the Winnipeg Children's Hospital, the only tertiary care pediatric centre in Manitoba. METHODS: We reviewed the charts, x-ray films and operative reports for 80 children under 16 years old (mean 9 yr, with 14 [18%] children between 2 and 4 yr) with an orthopedic injury sustained when using a trampoline in the backyard. We noted the mechanism of injury and type and severity of orthopedic injury sustained. RESULTS: Fifty-two (65%) children were injured on the trampoline mat, and 24 (30%) were injured when they were ejected from the trampoline. Sixty (75%) children sustained a fracture or fracture-dislocation. Forty-eight (80%) orthopedic injuries occurred in the upper extremity. No child died as a result of a trampoline injury. CONCLUSION: The use of the "backyard" trampoline by young children can cause significant orthopedic injury.