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.

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.

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.

The use of the Panda-Nerve Block pain app in single-shot peripheral nerve block patients: a feasibility study.

PURPOSE: Peripheral nerve blocks (PNBs) provide excellent perioperative analgesia but can increase the risk of severe postoperative pain once the block wears off. Poor adherence to discharge instructions may increase this risk. Panda-Nerve Block (Panda) is an app that alerts the patient to assess their PNB, score their pain, and take scheduled pain medication. We assessed the usability and feasibility of Panda for assisting patients after receiving a PNB. METHODS: Twenty-nine patients tested Panda in three rounds, for two to seven days, postoperatively to assess and manage their pain and PNB. Feedback was provided via phone interview and the Computer System Usability Questionnaire (CSUQ). Additionally, each user's usage log was analyzed for parameters such as alert response times. Feasibility was determined by alert responses that occurred before the next alert, with a goal of greater than 50%. User adherence was measured as percentage compliance with alerts within one hour; usability and user satisfaction were determined from the CSUQ and interviews. RESULTS: A median [interquartile range (IQR)] of 68 [34-93]% responded before the next alert during the first 48 hr of app use, and 83 [54-92]% responded before the next alert with 87 [75-96]% of these within one hour. There were no significant differences in usage between rounds. Ninety-three percent of patients reported Panda to be easy to use and helpful, and 79% of patients would use Panda again. Critical themes included changes to the layout and appearance, clarification of the language of the PNB check, and requests for dynamic adjustments to the medication schedule based on user responses. CONCLUSION: Panda-Nerve Block is a feasible method for PNB patients to manage postoperative pain with a high response rate. Future work should include providing two-way communication for patients and clinicians and assessing its effect on pain outcomes. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03369392); registered 5 December 2017.

RéSUMé: OBJECTIF: Les blocs nerveux périphériques (BNP) procurent une excellente analgésie périopératoire mais peuvent augmenter le risque de douleur postopératoire élevée une fois que le bloc disparait. Un mauvais respect des instructions de congé pourrait augmenter ce risque. L'application Panda (Panda-Nerve Block) avertit le patient afin qu'il évalue son BNP, quantifie sa douleur, et prenne ses médicaments analgésiques prescrits. Nous avons évalué la facilité d'utilisation et la faisabilité de l'application Panda pour aider les patients ayant reçu un BNP. MéTHODE: Vingt-neuf patients ont testé l'application Panda en trois itérations de deux à sept jours après leur opération afin d'évaluer et de prendre en charge leur douleur et le BNP. Les rétroactions étaient partagées par entretien téléphonique et via le Questionnaire sur la convivialité du système informatique (CSUQ - Computer System Usability Questionnaire). En outre, le journal d'utilisation de chaque utilisateur a été analysé pour en étudier certains paramètres tels que les temps de réponse aux alertes. La faisabilité était déterminée par les réponses aux alertes survenant avant la prochaine alerte, avec un objectif de plus de 50 %. L'observance des utilisateurs était mesurée en tant que pourcentage de conformité aux alertes dans l'heure suivante; la facilité d'utilisation et la satisfaction des utilisateurs étaient déterminées à partir du CSUQ et des entretiens. RéSULTATS: En moyenne [écart interquartile (ÉIQ)], 68 [34­93] % des patients ont répondu avant la prochaine alerte au cours des premières 48 h d'utilisation de l'application, et 83 [54­92] % ont répondu avant la prochaine alerte, avec 87 [75­96] % de ces patients dans l'heure qui suivait. Il n'y a pas eu de différence significative dans l'utilisation entre les itérations. Quatre-vingt-treize pour cent des patients ont rapporté qu'ils trouvaient l'application Panda conviviale et utile, et 79 % l'utiliseraient à nouveau. Les critiques comprenaient des modifications de la disposition et de l'apparence de l'application, la clarification du langage lors des vérifications du BNP, et des demandes pour des ajustements dynamiques du traitement selon les réponses des utilisateurs. CONCLUSION: L'application Panda constitue une méthode possible de prise en charge de la douleur postopératoire pour les patients ayant reçu un BNP, avec un taux de réponse élevé. Les travaux futurs devraient inclure la fourniture d'une communication bidirectionnelle pour les patients et les cliniciens et l'évaluation de l'effet de l'utilisation de l'application sur des devenirs de douleur. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03369392); enregistrée le 5 décembre 2017.

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.

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.

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.