Readability and quality assessment of online patient education materials for spinal and epidural anesthesia.

PURPOSE: Guidelines recommend that health-related information for patients should be written at or below the sixth-grade level. We sought to evaluate the readability level and quality of online patient education materials regarding epidural and spinal anesthesia. METHODS: We evaluated webpages with content written specifically regarding either spinal or epidural anesthesia, identified using 11 relevant search terms, with seven commonly used readability formulas: Flesh-Kincaid Grade Level (FKGL), Gunning Fox Index (GFI), Coleman-Liau Index (CLI), Automated Readability Index (ARI), Simple Measure of Gobbledygook (SMOG), Flesch Reading Ease (FRE), and New Dale-Chall (NDC). Two evaluators assessed the quality of the reading materials using the Brief DISCERN tool. RESULTS: We analyzed 261 webpages. The mean (standard deviation) readability scores were: FKGL = 8.8 (1.9), GFI = 11.2 (2.2), CLI = 10.3 (1.9), ARI = 8.1 (2.2), SMOG = 11.6 (1.6), FRE = 55.7 (10.8), and NDC = 5.4 (1.0). The mean grade level was higher than the recommended sixth-grade level when calculated with six of the seven readability formulas. The average Brief DISCERN score was 16.0. CONCLUSION: Readability levels of online patient education materials pertaining to epidural and spinal anesthesia are higher than recommended. When we evaluated the quality of the information using a validated tool, the materials were found to be just below the threshold of what is considered good quality. Authors of educational materials should provide not only readable but also good-quality information to enhance patient understanding.

RéSUMé: OBJECTIF: Les lignes directrices recommandent que les informations relatives à la santé destinées aux patient·es soient rédigées pour un niveau de sixième année ou en dessous. Nous avons cherché à évaluer le niveau de lisibilité et la qualité des matériels d'éducation disponibles en ligne pour les patient·es concernant l'anesthésie péridurale et la rachianesthésie. MéTHODE: Nous avons évalué les pages web dont le contenu était spécifiquement rédigé à propos de l'anesthésie rachidienne ou péridurale, identifiées à l'aide de 11 termes de recherche pertinents, avec sept formules de lisibilité couramment utilisées : Niveau scolaire Flesh-Kincaid (FKGL), Indice Gunning Fox (GFI), Indice Coleman-Liau (CLI), Indice de lisibilité automatisé (ARI), Mesure simple du charabia (SMOG), Facilité de lecture de Flesch (FRE) et New Dale-Chall (NDC). Deux personnes ont évalué la qualité du matériel de lecture à l'aide de l'outil Brief DISCERN. RéSULTATS: Nous avons analysé 261 pages web. Les scores de lisibilité moyens (écart type) étaient les suivants : FKGL = 8,8 (1,9), GFI = 11,2 (2,2), CLI = 10,3 (1,9), ARI = 8,1 (2,2), SMOG = 11,6 (1,6), FRE = 55,7 (10,8) et NDC = 5,4 (1,0). Le niveau de lecture moyen était plus élevé que le niveau recommandé de sixième année lorsqu'il a été calculé à l'aide de six des sept formules de lisibilité. Le score moyen de Brief DISCERN était de 16,0. CONCLUSION: Les niveaux de lisibilité des documents d'éducation en ligne relatifs à l'anesthésie péridurale et à la rachianesthésie destinés aux patient·es sont plus élevés que ceux recommandés. Lorsque nous avons évalué la qualité de l'information à l'aide d'un outil validé, nous avons constaté que les documents se situaient juste en dessous du seuil de ce qui est considéré comme de bonne qualité. Les personnes rédigeant du matériel éducatif doivent fournir des informations non seulement lisibles, mais aussi de bonne qualité afin d'améliorer la compréhension des patient·es.

Post-partum maternal bradycardia: A case series and literature review.

Background: Unlike tachyarrhythmias, which are common in pregnancy, there is a paucity of data regarding maternal bradycardias. Our objective was to describe the characteristics, associated conditions, and prognosis of women who develop bradycardia post-partum. Method: We conducted a retrospective chart review of patients referred to the Obstetrical Medicine service at British Columbia Women's Hospital from January 2012 to May 2020 for post-partum maternal bradycardia. Results: Twenty-four patients with post-partum bradycardia were included (age 34.2 ± 4.8 years; heart rate 40.4 ± 8.1 beats per minute; blood pressure 131/72 mm Hg). Sinus bradycardia (79.2%) was the most common rhythm. Dyspnea (29.4%) and chest pain (23.5%) were common symptoms. Mean time to resolution of bradycardia was 3.6 ± 3.8 days. Associated conditions potentially explaining the bradycardia were preeclampsia (54.1%), underlying (16.7%), medications (8.3%), and neuraxial anesthesia (8.3%). Conclusions: Maternal bradycardia is an uncommon condition complicating the post-partum period, that is generally self-limiting, with the majority only require clinical observation.

Guidelines to the Practice of Anesthesia-Revised Edition 2024.

OVERVIEW: The Guidelines to the Practice of Anesthesia-Revised Edition 2024 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia-Revised Edition 2024 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgement in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2024 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2024, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patient·es, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient·e. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

The efficacy of post-operative drains for anterior cervical discectomy and fusion: a systematic review and meta-analysis.

BACKGROUND: Controversy remains with the use of post-operative subfascial drains for anterior cervical discectomy and fusion, with limited guidelines and a paucity of conclusive evidence. Thus, the aim of this meta-analysis was to analyse and collate an evidence summary to determine the efficacy of such drains. METHODS: A systematic search of Medline (2002-2022.11), PubMed (2003-2022.11), Scopus (2002-2022.11), Cochrane Library (2015-2022.11) databases and reference lists of articles was conducted as per Cochrane systematic reviews standards. All relevant RCTs and NRCTs were included in this study. Data was extracted in a standardised form and analysed with RevMan version 5.4.1. Bias was assessed with RoB2 tool for RCTs and ROBINS-E tool for NRCTs. RESULTS: Two RCTs (136 patients) and five NRCTs (7563 patients) were included. These had a moderate to high risk of bias, except for one very high-risk article. Meta-analysis results showed no significant differences for post-operative haematoma (P = 0.31), surgical site infection (P = 0.84), take back to theatre (P = 0.27), length of stay (P = 0.34), and estimated blood loss (P = 0.09). Dysphagia (P = 0.002) and median operative time (P = 0.02) were significantly increased in the drain cohort. CONCLUSION: The low quality of available data in the included studies is insufficient to estimate the effect of post-operative drains for elective spondylotic ACDF. The findings suggest that if the decision to leave a drain in is left to the surgeon, then there is no difference in the rates of POH, SSI, LOS, or take back to the theatre. The significant association of dysphagia and increased operative time with drains, and the non-significant trend towards increased EBL with drains, must be considered in the context in which procedures may influence the decision to place drains. The results could not be stratified by various confounders that affect the decision-making process, including the number of levels operated. Due to the decreased quality and amount of evidence available, large-scale RCTs that adequately account for confounders should be performed.

Rotational Thromboelastometry-Guided Use of Synthetic Blood Products in Cardiac Transplant Patients: A Retrospective Before-After Study.

OBJECTIVES: Viscoelastic hemostatic assays, such as rotational thromboelastometry (ROTEM), are used increasingly in cardiac surgery to guide transfusion decisions. After separation from cardiopulmonary bypass (CPB), achieving hemostasis rapidly is the main goal before chest closure. The authors hypothesized that introducing a ROTEM-guided factor- concentrate transfusion algorithm would reduce the duration from CPB separation to chest closure during cardiac transplantation. DESIGN: A retrospective cohort study of 21 patients before and 28 patients after implementation of the ROTEM-guided transfusion algorithm who underwent cardiac transplantation. SETTING: This single-center study was conducted at Saint Paul's Hospital, Vancouver, British Columbia, Canada. INTERVENTIONS: Using a ROTEM-guided factor-concentrate transfusion algorithm for cardiac transplant recipients. MEASUREMENT AND MAIN RESULTS: The primary outcome was the duration from CPB separation to chest closure analyzed using Mann-Whitney U tests. The secondary outcomes included the volume of postoperative chest tube drainage, packed red blood cell (pRBC) transfusion requirements within 24 hours of surgery, the incidence of adverse events, and the length of stay before and after introducing a ROTEM-guided factor-concentrate transfusion algorithm. After adjusting for confounders using multivariate linear regression analysis, using a ROTEM-guided factor-concentrate transfusion algorithm resulted in a significant decrease in time from CPB separation to skin closure of 39.4 minutes (-73.1 to 123.5 min, p = 0.016). For the secondary outcomes, the use of ROTEM-guided transfusion showed reductions in pRBC transfusion within 24 hours of surgery (-1.3 units, -2.7 to 0.1 units; p = 0.077) and chest tube bleeding (-0.44 mL, -0.96 to +0.083 mL; p = 0.097); however, neither was statistically significant after adjustment. The median hospital length of stay in the study group was lower by 3 days (13 days v 16) days; p = 0.048). CONCLUSION: The introduction of a ROTEM-guided factor-concentrate transfusion algorithm was associated with a significant reduction in time to chest closure after separation from CPB. Although it reduced the total hospital length of stay, there were no differences in mortality, major complications, or intensive care unit length of stay.

Guidelines to the Practice of Anesthesia: Revised Edition 2023.

OVERVIEW: The Guidelines to the Practice of Anesthesia Revised Edition 2023 (the Guidelines) were prepared by the Canadian Anesthesiologists' Society (CAS), which reserves the right to determine their publication and distribution. The Guidelines are subject to revision and updated versions are published annually. The Guidelines to the Practice of Anesthesia Revised Edition 2023 supersede all previously published versions of this document. Although the CAS encourages Canadian anesthesiologists to adhere to its practice guidelines to ensure high-quality patient care, the CAS cannot guarantee any specific patient outcome. Anesthesiologists should exercise their own professional judgment in determining the proper course of action for any patient's circumstances. The CAS assumes no responsibility or liability for any error or omission arising from the use of any information contained in its Guidelines to the Practice of Anesthesia.

RéSUMé: Le Guide d'exercice de l'anesthésie, version révisée 2023 (le Guide), a été préparé par la Société canadienne des anesthésiologistes (SCA), qui se réserve le droit de décider des termes de sa publication et de sa diffusion. Le Guide est soumis à révision et des versions mises à jour sont publiées chaque année. Le Guide d'exercice de l'anesthésie, version révisée 2023, remplace toutes les versions précédemment publiées de ce document. Bien que la SCA incite les anesthésiologistes du Canada à se conformer à son guide d'exercice pour assurer une grande qualité des soins dispensés aux patients, elle ne peut garantir les résultats d'une intervention spécifique. Les anesthésiologistes doivent exercer leur jugement professionnel pour déterminer la méthode d'intervention la mieux adaptée à l'état de leur patient. La SCA n'accepte aucune responsabilité ou imputabilité de quelque nature que ce soit découlant d'erreurs ou d'omissions ou de l'utilisation des renseignements contenus dans son Guide d'exercice de l'anesthésie.

Theoretical Schemas to Guide Back Pain Consortium (BACPAC) Chronic Low Back Pain Clinical Research.

BACKGROUND: Chronic low back pain (cLBP) is a complex with a heterogenous clinical presentation. A better understanding of the factors that contribute to cLBP is needed for accurate diagnosis, optimal treatment, and identification of mechanistic targets for new therapies. The Back Pain Consortium (BACPAC) Research Program provides a unique opportunity in this regard, as it will generate large clinical datasets, including a diverse set of harmonized measurements. The Theoretical Model Working Group was established to guide BACPAC research and to organize new knowledge within a mechanistic framework. This article summarizes the initial work of the Theoretical Model Working Group. It includes a three-stage integration of expert opinion and an umbrella literature review of factors that affect cLBP severity and chronicity. METHODS: During Stage 1, experts from across BACPAC established a taxonomy for risk and prognostic factors (RPFs) and preliminary graphical depictions. During Stage 2, a separate team conducted a literature review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to establish working definitions, associated data elements, and overall strength of evidence for identified RPFs. These were subsequently integrated with expert opinion during Stage 3. RESULTS: The majority (∼80%) of RPFs had little strength-of-evidence confidence, whereas seven factors had substantial confidence for either a positive association with cLBP (pain-related anxiety, serum C-reactive protein, diabetes, and anticipatory/compensatory postural adjustments) or no association with cLBP (serum interleukin 1-beta / interleukin 6, transversus muscle morphology/activity, and quantitative sensory testing). CONCLUSION: This theoretical perspective will evolve over time as BACPAC investigators link empirical results to theory, challenge current ideas of the biopsychosocial model, and use a systems approach to develop tools and algorithms that disentangle the dynamic interactions among cLBP factors.

Spontaneous Angiolipoma in Autologous Flap Reconstruction.

Breast cancer recurrence after autologous flap reconstruction is rare and typically occurs at the contact zone between the flap and the native tissue. When a new lesion is found in a reconstructed breast without the characteristic appearance of benign entities such as fat necrosis, definitive tissue diagnosis is often warranted to rule out recurrence or metastasis. Angiolipomas are rare, benign lipomatous tumors that have nonspecific imaging appearances and are thus frequently biopsied or excised for definitive diagnosis. Here, we report a case of a new breast mass found at the contact zone of a reconstructed breast in a patient with a history of ductal carcinoma in situ (DCIS), which was ultimately excised and proven to be an angiolipoma.

A novel ultrasound software system for lumbar level identification in obstetric patients.

PURPOSE: Using machine learning, we developed a proprietary ultrasound software called the Spine Level Identification (SLIDE) system, which automatically identifies lumbar landmarks in real time as the operator slides the transducer over the lumber spine. Here, we assessed the agreement between SLIDE and manual palpation and traditional lumbar ultrasound (LUS) for determining the primary target L3-4 interspace. METHODS: Upon institutional ethics approval and informed consent, 76 healthy term parturients scheduled for elective Caesarean delivery were recruited. The L3-4 interspace was identified by manual palpation and then by the SLIDE method. The reference standard was located using traditional LUS by an experienced operator. The primary outcome was the L3-4 interspace identification agreement of manual palpation and SLIDE with the reference standard, as percentage agreement and Gwet's agreement coefficient (AC1). RESULTS: The raw agreement was 70% with Gwet's agreement coefficient (AC1) = 0.59 (95% confidence interval [CI], 0.41 to 0.77) for manual palpation and 84% with Gwet's AC1 = 0.82 (95% CI, 0.70 to 0.93) for SLIDE. When the levels differ from the reference, the manual palpation method identified L2-3 more often than L4-5 while the SLIDE method identified equally above or below L3-4. The SLIDE system had greater agreement than palpation in locating L3-4 and all other lumber interspaces after controlling for body mass index (adjusted odds ratio, 2.99; 95% CI, 1.21 to 8.7; P = 0.02). CONCLUSION: The SLIDE system had higher agreement with traditional ultrasound than manual palpation did in identifying L3-4 and all other lumber interspaces after adjusting for BMI in healthy term obstetric patients. Future studies should examine factors that affect agreement and ways to improve SLIDE for clinical integration. STUDY REGISTRATION: www. CLINICALTRIALS: gov (NCT02982317); registered 5 December 2016.

RéSUMé: OBJECTIF: À l'aide de l'apprentissage automatique, nous avons développé un logiciel d'échographie propriétaire appelé SLIDE (pour Spine Level Identification, c.-à-d. système d'identification du niveau vertébral), qui identifie automatiquement les points de repère lombaires en temps réel lorsque l'opérateur fait passer le transducteur sur la colonne lombaire. Ici, nous avons évalué l'agrément entre le SLIDE et la palpation manuelle et l'échographie lombaire traditionnelle pour déterminer l'espace intervertébral cible principal L3­L4. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique de l'établissement et le consentement éclairé, 76 parturientes en bonne santé et à terme devant bénéficier d'un accouchement par césarienne programmée ont été recrutées. L'espace intervertébral L3­L4 a été identifié par palpation manuelle puis avec le logiciel SLIDE. L'étalon de référence a été localisé à l'aide d'une échographie lombaire traditionnelle par un opérateur expérimenté. Le critère d'évaluation principal était l'agrément entre l'identification de l'espace intervertébral L3­L4 par palpation manuelle et par logiciel SLIDE avec l'étalon de référence, en pourcentage d'agrément et coefficient d'agrément de Gwet (CA1). RéSULTATS: L'agrément brut était de 70 % avec le coefficient d'agrément de Gwet (CA1) = 0,59 (intervalle de confiance [IC] à 95 %, 0,41 à 0,77) pour la palpation manuelle et de 84 % avec le CA1 de Gwet = 0,82 (IC 95 %, 0,70 à 0,93) pour le logiciel SLIDE. Lorsque les niveaux lombaires différaient de la référence, la méthode de palpation manuelle a identifié L2­L3 plus souvent que L4­L5, tandis que la méthode SLIDE a identifié les vertèbres supérieures ou inférieures à L3­L4 de manière égale. Le système SLIDE a affiché un agrément plus important que la palpation pour localiser L3­L4 et tous les autres espaces intervertébraux lombaires après ajustement pour tenir compte de l'indice de masse corporelle (rapport de cotes ajusté, 2,99; IC 95 %, 1,21 à 8,7; P = 0,02). CONCLUSION: Le système SLIDE avait affiché un agrément plus élevé avec l'échographie traditionnelle que la palpation manuelle pour identifier le niveau L3­L4 et tous les autres espaces intervertébraux lombaires après ajustement pour tenir compte de l'IMC chez les patientes obstétricales à terme en bonne santé. Une étude future devrait examiner les facteurs qui affectent l'agrément et les moyens d'améliorer le logiciel SLIDE pour une intégration clinique. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT02982317); enregistrée le 5 décembre 2016.

Incidence, prevalence, and timing of postpartum complications and mortality in Canada and the United States: a systematic review and meta-analysis protocol.

OBJECTIVE: The goal of this systematic review is to assess the incidence, prevalence, and timing of common postpartum (up to 1 year after delivery) medical, surgical/procedural, and psychosocial complications and mortality. INTRODUCTION: Childbirth is the most common cause for hospitalization, and cesarean delivery is the most commonly performed inpatient surgery. After delivery, mothers are at risk of short- and long-term complications that can impact their well-being. The results of this review will inform evidence-based recommendations for patient education, monitoring, and follow-up. INCLUSION CRITERIA: We will include studies performed in Canada and/or the United States that report the incidence or prevalence of medical, procedural/surgical, and psychosocial complications within 1 year postpartum. Observational studies (analytical cross-sectional studies, retrospective and prospective cohorts), randomized or non-randomized controlled trials with a control or standard of care group, systematic reviews, and meta-analyses will be included. Studies with fewer than 100 patients, participants younger than 18 years, no reporting of duration, or focus on patients with a specific condition rather than a general postpartum population will be excluded. METHODS: The search strategy was codeveloped with a medical librarian and included full-text English-language articles published within the past 10 years (2011-2021) in PubMed, CINHAL, Web of Science, and Cochrane Database of Systematic Reviews. Screening, critical appraisal, and data extraction will be performed by two independent reviewers using Covidence, standardized JBI tools, and a standardized form, respectively. For each complication, the incidence or prevalence, timing of the frequency measurement, and duration of follow-up from individual studies will be determined. Meta-analysis will be performed if feasible. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42022303047.

Management of acute aortoiliac arterial thrombosis in patients with the novel coronavirus disease 2019: A case series and systematic review of the literature.

Objectives: Venous thrombosis has been widely described in the setting of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection; however, arterial thrombosis has rarely been reported. This study aims to assess the incidence, risk factors, interventions, and outcomes of acute aortoiliac arterial thrombosis in patients with active SARS-CoV-2 infections. Methods: We present seven SARS-CoV-2-positive patients from our institution who acutely developed thrombi in the aortoiliac arterial system (7/2020-1/2021). A systematic review of the literature on aortoiliac arterial thrombosis in patients with SARS-CoV-2 infections in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was also performed. The available data from all reported cases in the literature and at our institution were analyzed. Results: Thirty published articles and journal correspondences, including 52 patients, were reviewed and analyzed in addition to our institution's 7 cases. In total, 59 SARS-CoV-2-positive patients were found to have acute aortoiliac thrombosis. The abdominal aorta was the most frequent location for the development of a thrombus. Baseline demographics and medical comorbidities were not significantly different between the symptomatic and asymptomatic cohorts. Seventy-one percent of patients were symptomatic (lower limb ischemia: 75.0%, renal infarction: 20.0%, stroke: 12.5%, mesenteric ischemia: 10.0%). All patients with thrombus involving the ascending aorta, aortic bifurcation, or iliac artery developed thromboembolic or ischemic complications. All patients received systemic anticoagulation. Fifty-three percent of all patients were managed medically. Ninety-four percent of the asymptomatic patients were managed medically. One asymptomatic patient underwent endovascular aspiration of a mobile thrombus. Three (23.1%) deaths occurred in the asymptomatic cohort from hypoxic respiratory failure. Fourteen (36.8%) deaths occurred in the symptomatic cohort. The in-hospital mortality rate was 33.3% overall and 43.8% for patients with thrombi involving more than one aortoiliac segment. Conclusions: The presence of thrombi in the aortoiliac arterial system appears to be a poor prognostic indicator for patients with active SARS-CoV-2 infections. Medical management of patients with asymptomatic aortoiliac thrombi may be considered. The presence of thrombi involving the ascending aorta, aortic bifurcation, or iliac artery may warrant consideration for operative intervention due to the risk for thromboembolic or ischemic complications. Further study is needed to fully delineate the risk factors, optimal treatment, and outcomes of arterial thrombosis in the setting of SARS-CoV-2 infection.

Intramesenteric abscess caused by non-typhoidal Salmonella.

Nontyphoidal Salmonella (NTS) is a common cause of gastroenteritis in humans and animals, but intra-abdominal abscesses or organ space surgical site infection (SSI) secondary to this organism has been rarely reported, making diagnosis and management difficult. Our case of intra-mesenteric abscess caused by NTS species is the only case reported in the literature. Immunocompromising conditions such as diabetes and human immunodeficiency virus (HIV) are important risk factors for invasive nontyphoidal Salmonella. Most patients are treated initially with intravenous antibiotics. Treatment often requires operative drainage by laparoscopy or laparotomy alone, although percutaneous drainage has been performed more frequently in recent years. Early clinical signs and radiographic features of intra-abdominal abscess may be diagnostically challenging. It is important for clinicians to have high index of suspicion based on history and symptomatology as prompt treatment is essential to prevent further morbidity and mortality.

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.

Neuraxial labor analgesia: Initiation techniques.

The ideal technique for labor analgesia would have a quick onset, predictable quality, and adjustable depth and duration. Moreover, it would be easy to perform and have minimal maternal and fetal side effects. A catheter-based neuraxial approach encompasses these desirable characteristics and includes the epidural, combined spinal epidural, dural puncture epidural, and intrathecal catheter techniques. In this review, we outline the unique technical considerations, analgesic characteristics, and side effect profiles for each technique that can ultimately impact the maternal-fetal dyad. The selection of neuraxial analgesia techniques should consider the patient and team's goals and expectations, the clinical context, and the institutional culture. Labor analgesic techniques that initiate with an intentional dural puncture component have a faster onset, greater bilateral and sacral spread, and lower rates of epidural catheter failure. Further elucidation of the mechanisms, benefits, and risks of each neuraxial initiation technique will continue to benefit patients and care providers.

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.

Enhancing knowledge, skills, and comfort in providing anesthesia assistance during obstetric general anesthesia for operating room nurses: a prospective observational study.

BACKGROUND: Due to a nationwide shortage of anesthesia assistants, operating room nurses are often recruited to assist with the induction of obstetric general anesthesia (GA). We developed and administered a training program and hypothesized there would be significant improvements in knowledge and skills in anesthesia assistance during obstetric GA by operating room nurses following training with adequate retention at six months. METHODS: Following informed consent, all operating room nurses at our institution were invited to participate in the study. Baseline knowledge of participants was assessed using a 14-item multiple choice questionnaire (MCQ), and skills were assessed using a 12-item checklist scored by direct observation during simulated induction of GA. Next, a 20-min didactic lecture followed by a ten-minute hands-on skills station were delivered. Knowledge and skills were immediately reassessed after training, and again at six weeks and six months. The primary outcomes of this study were adequate knowledge and skills retention at six months, defined as achieving ≥ 80% in MCQ and ≥ 80% in skills checklist scores and analyzed using longitudinal mixed-effects linear regression. RESULTS: A total of 34 nurses completed the study at six months. The mean MCQ score at baseline was 8.9 (95% confidence interval [CI], 8.5 to 9.4) out of 14. The mean skills checklist score was 5.5 (95% CI, 4.9 to 6.1) out of 12. The mean comfort scores for assisting elective and emergency Cesarean deliveries were 3.6 (95% CI, 3.2 to 3.9) and 3.1 (95% CI, 2.7 to 3.5) out of 5, respectively. There was a significant difference in the mean MCQ and skills checklist scores across the different study periods (overall P value < 0.001). Post hoc pairwise tests suggested that, compared with baseline, there were significantly higher mean MCQ scores at all time points after the training program at six weeks (11.9; 95% CI, 11.4 to 12.4; P < 0.001) and at six months (12.0; 95% CI, 11.5 to 12.4; P < 0.001). DISCUSSION: The knowledge and skills of operating room nurses in providing anesthesia assistance during obstetric GA at our institution were low at baseline. Following a single 30-min in-house, anesthesiologist-led, structured training program, scores in both dimensions significantly improved. Although knowledge improvements were adequately retained for up to six months, skills improvements decayed rapidly, suggesting that sessions should be repeated at six-week intervals, at least initially.

RéSUMé: CONTEXTE: En raison d'une pénurie nationale d'assistants en anesthésie, le personnel infirmier de la salle d'opération est souvent sollicité pour aider à l'induction de l'anesthésie générale (AG) obstétricale. Nous avons élaboré et administré un programme de formation et émis l'hypothèse qu'il y aurait des améliorations significatives dans les connaissances et les compétences en matière d'assistance en anesthésie pendant l'anesthésie générale obstétricale par les infirmières de salle d'opération après avoir suivi une formation, avec une rétention adéquate à six mois. MéTHODE: Après avoir obtenu le consentement éclairé, tout le personnel infirmier de salle d'opération de notre établissement a été invité à participer à l'étude. Les connaissances de base des participants ont été évaluées à l'aide d'un questionnaire à choix multiples (QCM) à 14 éléments, et les compétences ont été évaluées à l'aide d'une liste de contrôle de 12 éléments notée par observation directe lors d'une simulation d'induction d'anesthésie générale. Par la suite, un cours didactique de 20 minutes suivi d'une station de compétences pratiques de dix minutes a été donné. Les connaissances et les compétences ont été réévaluées immédiatement après la formation, puis de nouveau à six semaines et six mois. Les critères d'évaluation principaux de cette étude étaient la rétention adéquate des connaissances et des compétences à six mois, définie comme l'atteinte de ≥ 80 % dans les scores du QCM et ≥ 80 % dans les scores de la liste de contrôle des compétences et analysée à l'aide d'une régression linéaire longitudinale à effets mixtes. RéSULTATS: Au total, 34 infirmières ont terminé l'étude à six mois. Au début de l'étude, le score moyen au QCM était de 8,9 (intervalle de confiance [IC] à 95 %, 8,5 à 9,4) sur 14. Le score moyen sur la liste de contrôle des compétences était de 5,5 (IC 95 %, 4,9 à 6,1) sur 12. Les scores moyens d'aisance dans l'assistance pour un accouchement par césarienne programmé et d'urgence étaient de 3,6 (IC 95 %, 3,2 à 3,9) et 3,1 (IC 95 %, 2,7 à 3,5) sur 5, respectivement. Une différence significative a été observée dans les scores moyens au QCM et sur la liste de contrôle des compétences entre les différentes périodes d'étude (valeur globale P < 0,001). Les tests appariés post-hoc ont suggéré que, par rapport aux connaissances évaluées au début de l'étude, les scores moyens au QCM étaient significativement plus élevés à tous les moments après le programme de formation, à six semaines (11,9; IC 95 %, 11,4 à 12,4; P < 0,001) et à six mois (12,0; IC 95 %, 11,5 à 12,4; P < 0,001). DISCUSSION: Les connaissances et les compétences du personnel infirmier de salle d'opération dans la prestation d'une assistance en anesthésie pendant l'AG obstétricale dans notre établissement étaient faibles au commencement de notre étude. Après un seul programme de formation structuré de 30 minutes à l'interne, dirigé par un anesthésiologiste, les scores dans les deux dimensions se sont considérablement améliorés. Bien que les améliorations des connaissances aient été retenues de manière adéquate jusqu'à six mois, les améliorations des compétences se sont rapidement détériorées, ce qui suggère que les séances devraient être répétées à des intervalles de six semaines, au moins au début.