Validity of non-contact methods for diagnosis of Obstructive Sleep Apnea: a systematic review and meta-analysis.

STUDY OBJECTIVE: Obstructive Sleep Apnea (OSA) is associated with increased perioperative cardiac, respiratory and neurological complications. Pre-operative OSA risk assessment is currently done through screening questionnaires with high sensitivity but poor specificity. The objective of this study was to evaluate the validity and diagnostic accuracy of portable, non-contact devices in the diagnosis of OSA as compared with polysomnography. DESIGN: This study is a systematic review of English observational cohort studies with meta-analysis and risk of bias assessment. SETTING: Pre-operative, including in the hospital and clinic setting. PATIENTS: Adult patients undergoing sleep apnea assessment using polysomnography and an experimental non-contact tool. INTERVENTIONS: A novel non-contact device, which does not utilize any monitor that makes direct contact with the patient's body, in conjunction with polysomnography. MEASUREMENTS: Primary outcomes included pooled sensitivity and specificity of the experimental device in the diagnosis of obstructive sleep apnea, in comparison to gold-standard polysomnography. RESULTS: Twenty-eight of 4929 screened studies were included in the meta-analysis. A total of 2653 patients were included with the majority being patients referred to a sleep clinic (88.8%). Average age was 49.7(SD±6.1) years, female sex (31%), average body mass index of 29.5(SD±3.2) kg/m2, average apnea-hypopnea index (AHI) of 24.7(SD±5.6) events/h, and pooled OSA prevalence of 72%. Non-contact technology used was mainly video, sound, or bio-motion analysis. Pooled sensitivity and specificity of non-contact methods in moderate to severe OSA diagnosis (AHI > 15) was 0.871 (95% CI 0.841,0.896, I2 0%) and 0.8 (95% CI 0.719,0.862), respectively (AUC 0.902). Risk of bias assessment showed an overall low risk of bias across all domains except for applicability concerns (none were conducted in the perioperative setting). CONCLUSION: Available data indicate contactless methods have high pooled sensitivity and specificity for OSA diagnosis with moderate to high level of evidence. Future research is needed to evaluate these tools in the perioperative setting.

Barriers to reducing preoperative testing for low-risk surgical procedures: A qualitative assessment guided by the Theoretical Domains Framework.

INTRODUCTION: While numerous guidelines do not recommend preoperative tests for low risk patients undergoing low risk surgeries, they are often routinely performed. Canadian data suggests preoperative tests (e.g. ECGs and chest x-rays) preceded 17.9%-35.5% of low-risk procedures. Translating guidelines into clinical practice can be challenging and it is important to understand what is driving behaviour when developing interventions to change it. AIM: Thus, we completed a theory-based investigation of the perceived barriers and enablers to reducing unnecessary preoperative tests for low-risk surgical procedures in Newfoundland, Canada. METHOD: We used snowball sampling to recruit surgeons, anaesthesiologists, or preoperative clinic nurses. Interviews were conducted by two researchers using an interview guide with 31 questions based on the theoretical domains framework. Data was transcribed and coded into the 14 theoretical domains and then themes were identified for each domain. RESULTS: We interviewed 17 surgeons, anaesthesiologists, or preoperative clinic nurses with 1 to 34 years' experience. Overall, while respondents agreed with the guidelines they described several factors, across seven relevant theoretical domains, that influence whether tests are ordered. The most common included uncertainty about who is responsible for test ordering, inability to access patient records or to consult/communicate with colleagues about ordering decisions and worry about surgery delays/cancellation if tests are not ordered. Other factors included workplace norms that conflicted with guidelines and concerns about missing something serious or litigation. In terms of enablers, respondents believed that clear institutional guidelines including who is responsible for test ordering and information about the risk of missing something serious, supported by improved communication between those involved in the ordering process and periodic evaluation will reduce any unnecessary preoperative testing. CONCLUSION: These findings suggest that both health system and health provider factors need to be addressed in an intervention to reduce pre-operative testing.

Impact of an extrafascial versus intrafascial injection for supraclavicular brachial plexus block on respiratory function: a randomized, controlled, double-blind trial.

INTRODUCTION: Hemidiaphragmatic paresis after ultrasound-guided supraclavicular brachial plexus block is reported to occur in up to 67% of patients. We tested the hypothesis that an injection outside the brachial plexus sheath reduces the incidence of hemidiaphragmatic paresis compared with an intrafascial injection while providing similar analgesia. METHODS: Fifty American Society of Anesthesiologists I-III patients scheduled for elective upper limb surgery received a supraclavicular brachial plexus block using 30 mL of 1:1 mixture of mepivacaine 1% and ropivacaine 0.5%. The block procedures were randomized to position the needle tip either within the brachial plexus after piercing the sheath (intrafascial injection) or outside the brachial plexus sheath (extrafascial injection). The primary outcome was the incidence of hemidiaphragmatic paresis 30 min after the injection, measured by M-mode ultrasonography. Additional outcomes included time to surgery readiness, and resting and dynamic pain scores at 24 hours postoperatively (Numeric Rating Scale, 0-10). RESULTS: The incidence of hemidiaphragmatic paresis 30 min after the injection was 9% (95% CI 1% to 29%) and 0% (95% CI 0% to 15%) in the intrafascial and extrafascial groups respectively (p=0.14). Extrafascial injection was associated with a longer time to surgery readiness (intrafascial: 18 min (95% CI: 16 to 21 min); extrafascial: 37 min (95% CI: 31 to 42 min); p<0.001). At 24 hours, resting and dynamic pain scores were similar between groups. DISCUSSION: Ultrasound-guided supraclavicular brachial plexus block with an extrafascial injection does not reduce the incidence of hemidiaphragmatic paresis although it provides similar analgesia, when compared with an intrafascial injection. The longer time to surgery readiness is less compatible with contemporary operating theater efficiency requirements. TRIAL REGISTRATION NUMBER: NCT03957772.

Standing out or fitting in: A latent projective content analysis of discrimination of women and 2SLGBTQ+ anesthesiologists and providers.

INTRODUCTION: Discrimination toward sex and gender minority anesthesiologists and anesthesia trainees exists. Potential reasons for this discrimination are unclear and incompletely characterized. This study sought to better understand what discrimination looks like for sex and gender minorities in anesthesiology and the culture within anesthesiology that allows this discrimination to occur. MATERIALS AND METHODS: With institutional research ethics board approval and informed consent, we performed a qualitative analysis of free-text responses from a previously-published internet-based cross-sectional survey distributed to Canadian anesthesiology residents, fellows, and staff. The purpose of this survey was to characterize intersections between respondent gender or sexuality with experiences of discrimination in the workplace. Separate analysis of qualitative and quantitative components of this survey was planned a priori, and the quantitative component was published elsewhere. Free-text responses were independently coded by two researchers and subsequently synthesized into emerging themes using latent projective content analysis sensitized by Butler's theory of performativity. RESULTS: Out of 490 free-text responses from 171 respondents [140 (81.9%) identifying as heterosexual], two themes emerged: i) fitting in: performativity reinforcing the status quo, and ii) standing out: performativity as a means of disruptive social change. Power structures were observed to favour individuals who "fit in" with the normative performances of gender and/or sexuality. DISCUSSION: Our study illuminates how individuals whose performances of gender and sexuality "fit in" with those expected normative performances reinforce a workplace culture that advantages them, whereas individuals whose performances of gender and sexuality "stand out" disproportionately experience discrimination. The dismantling of bias and discrimination in the anesthesiology workplace requires individuals (a) who are empowered within their workplace because they "fit in" with the majority; (b) who recognize discrimination toward communities of their peers and/or colleagues; and (c) who actively choose to "stand out".

The analgesic efficacy of transversus abdominis plane block vs. wound infiltration after inguinal and infra-umbilical hernia repairs: A systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Both transversus abdominis plane (TAP) block and wound infiltration with local anaesthetic have been used to relieve pain after inguinal or infra-umbilical hernia repair. OBJECTIVES: To determine whether TAP block or local anaesthetic infiltration is the best analgesic option after inguinal or infra-umbilical hernia repair. DESIGN: Systematic review and meta-analysis with trial sequential analysis. DATA SOURCES: MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science, up to June, 2020. ELIGIBILITY CRITERIA: We retrieved randomised controlled trials comparing TAP block with wound infiltration after inguinal or infra-umbilical hernia repair. Primary outcome was rest pain score (analogue scale 0 to 10) at 2 postoperative hours. Secondary pain-related outcomes included rest pain score at 12 and 24 h, and intravenous morphine consumption at 2, 12 and 24 h. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, haematoma, visceral injury and systemic toxicity of local anaesthetic. RESULTS: Seven trials including 420 patients were identified. There was a significant difference in rest pain score at 2 postoperative hours in favour of TAP block compared with wound infiltration, with a mean (95% confidence interval) difference of -0.8 (-1.3 to -0.2); I2  = 85%; P   =  0.01. Most secondary pain-related outcomes were also significantly improved following TAP block. No complication was reported. The overall quality of evidence was moderate. CONCLUSION: There is moderate level evidence that TAP block provides superior analgesia compared with wound infiltration following inguinal or infra-umbilical hernia repair. TRIAL REGISTRY NUMBER: PROSPERO CRD42020208053.

Transversus abdominis plane block versus local anaesthetic wound infiltration for analgesia after caesarean section: A systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Transversus abdominis plane (TAP) block and local anaesthetic wound infiltration are used to relieve pain after caesarean section. OBJECTIVES: To determine whether TAP block or local anaesthetic wound infiltration is the better analgesic option after caesarean section. DESIGN: Systematic review and meta-analysis with trial sequential analysis. DATA SOURCES: MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science up to June 2020. ELIGIBILITY CRITERIA: We retrieved randomised controlled trials comparing TAP block with wound infiltration after caesarean section. Primary outcome was pain score during rest (analogue scale, 0 to 10) at 2 h postoperatively, analysed according to the TAP block technique (ultrasound-guided/landmark-guided), anaesthetic strategy (spinal/general), intrathecal fentanyl (yes/no) and multimodal analgesia (yes/no). Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, and total intravenous morphine consumption at 2, 12 and 24 h. We sought rates of block complications, including postoperative infection, haematoma, visceral injury and local anaesthetic systemic toxicity. RESULTS: Seven trials, totalling 475 patients, were identified. There was no difference in pain score during rest at 2 h between groups. Subgroup analyses revealed no differences related to TAP block technique (P = 0.64), anaesthetic strategy (P = 0.53), administration of intrathecal fentanyl (P = 0.59) or presence of multimodal analgesia (P = 0.57). Pain score during rest at 12 h and intravenous morphine consumption at 2 and 12 h were identical in both groups. Data were insufficient to compare block complications. Overall quality of evidence was moderate. CONCLUSION: There is moderate level evidence that TAP block and wound infiltration provide similar postoperative analgesia after caesarean section. TRIAL REGISTRY NUMBER: PROSPERO CRD42020208046.

Transversus abdominis plane block versus local anesthetic wound infiltration for optimal analgesia after laparoscopic cholecystectomy: A systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Both transversus abdominis plane (TAP) block and local anesthetic wound infiltration have been used to relieve pain after laparoscopic cholecystectomy. We undertook this systematic review and meta-analysis with trial sequential analysis to determine the best analgesic technique. METHODS: We systematically searched the literature for trials comparing TAP block with wound infiltration after laparoscopic cholecystectomy. The primary outcome was pain score during rest (analogue scale, 0-10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores during rest at 12 and 24 h, pain scores during movement and intravenous morphine consumption at 2, 12 and 24 h, and postoperative nausea and vomiting. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, hematoma, visceral injury and local anesthetic systemic toxicity. RESULTS: Ten trials including 668 patients were identified. There was a significant difference in pain score during rest at 2 postoperative hours in favour of TAP block when compared with wound infiltration (mean difference [95%CI]: -0.7 [-1.2, -0.2]; I2 = 71%; p = 0.008). Pain scores during rest at 12 and 24 h and pain scores during movement at 24 h were also significantly lower with TAP block than wound infiltration. Postoperative morphine consumption and the incidence of postoperative nausea and vomiting were significantly lower in patients who received a TAP block. Data were insufficient to compare block-related complications. The overall quality of evidence was moderate-to-high. CONCLUSIONS: There is moderate-to-high level evidence that the TAP block provides superior analgesia when compared with wound infiltration in patients undergoing laparoscopic cholecystectomy. Trial registry number: PROSPERO CRD42020208057.

Combination of femoral triangle block and infiltration between the popliteal artery and the capsule of the posterior knee (iPACK) versus local infiltration analgesia for analgesia after anterior cruciate ligament reconstruction: a randomized controlled triple-blinded trial.

BACKGROUND AND OBJECTIVES: Femoral triangle block and local infiltration analgesia are two effective analgesic techniques after anterior cruciate ligament reconstruction. Recently, the iPACK block (infiltration between the popliteal artery and the capsule of the posterior knee) has been described to relieve posterior knee pain. This randomized controlled triple-blinded trial tested the hypothesis that the combination of femoral triangle block and iPACK provides superior analgesia to local infiltration analgesia after anterior cruciate ligament reconstruction. METHODS: Sixty patients undergoing anterior cruciate ligament reconstruction received general anesthesia and were randomly allocated to two groups: femoral triangle block and iPACK under ultrasound guidance or local infiltration analgesia. For each group, a total of 160 mg of ropivacaine was injected. Postoperative pain treatment followed a predefined protocol with intravenous morphine patient-controlled analgesia, acetaminophen, and ibuprofen. The primary outcome was cumulative intravenous morphine consumption at 24 hours postoperatively. Secondary pain-related outcomes included pain scores (Numeric Rating Scale out of 10) measured at 2 and 24 hours postoperatively. Functional outcomes, such as range of motion and quadriceps strength, were also recorded at 24 postoperative hours, and at 4 and 8 postoperative months. RESULTS: Cumulative intravenous morphine consumption at 24 hours postoperatively was significantly reduced in the femoral triangle block and iPACK group (femoral triangle block and iPACK: 9.7 mg (95% CI: 6.7 to 12.7); local infiltration analgesia: 17.0 mg (95% CI: 11.1 to 23.0), p=0.03). Other pain-related and functional-related outcomes were similar between groups. CONCLUSIONS: The combination of femoral triangle block and iPACK reduces intravenous morphine consumption during the first 24 hours after anterior cruciate ligament reconstruction, when compared with local infiltration analgesia, without effect on other pain-related, early, or late functional-related outcomes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Registry (NCT03680716).

Factors associated with success and failure of patient-controlled oral analgesia after total hip and knee arthroplasty: a historical comparative cohort study.

PURPOSE: Patient-controlled oral analgesia (PCOA) is a novel method of oral opioid administration using set doses of short-acting oral opioids self-administered by patients with a "lockout" period as part of a multimodal regimen. Failure of PCOA can result in severe postoperative pain necessitating use of intravenous patient-controlled analgesia (IV-PCA) with its potential complications. This study evaluated factors related to success or failure of PCOA following total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS: We conducted a retrospective cohort study of all adults who underwent THA and TKA at our institution by extracting data from the proprietary database of our acute pain service. Patient, anesthetic, and surgical variables associated with PCOA failure defined as inadequate analgesia requiring conversion to IV-PCA within 24 hr following THA and TKA were evaluated. Univariable and multivariable logistic regression analyses were performed to identify predictors of PCOA failure. RESULTS: Of the 926 patients who underwent THA or TKA (n = 411 and 515, respectively), 147 (15.9%) patients (67 THA and 80 TKA patients) had PCOA failure with moderate-to-severe pain. Multivariable regression analysis showed that PCOA failure occurred in those with younger age (adjusted odds ratio [aOR] per year of age, 0.97; 99% CI, 0.95 to 0.99; P < 0.001), preoperative chronic use of controlled-release opioids (aOR, 3.45; 99% CI, 1.60 to 7.35; P < 0.001), and with the use of general anesthesia vs spinal anesthesia (aOR, 2.86; 99% CI, 1.20 to 6.84; P = 0.002). CONCLUSION: The use of PCOA provides adequate analgesia to a majority of patients undergoing THA and TKA. Factors predictive for PCOA failure should be considered when choosing the primary breakthrough analgesic modality following THA/TKA.

RéSUMé: OBJECTIF: L'analgésie orale contrôlée par le patient (AOCP) est une méthode novatrice d'administration d'opioïdes oraux qui utilise des doses pré-établies d'opioïdes oraux à courte action auto-administrées par les patients avec un intervalle minimal entre les doses dans le cadre d'un régime multimodal. Le non-fonctionnement d'une AOCP peut entraîner une douleur postopératoire grave nécessitant le recours à une analgésie intraveineuse contrôlée par le patient (ACP-IV), ce qui s'accompagne de complications potentielles. Cette étude a évalué les facteurs liés à la réussite ou à l'échec de l'AOCP à la suite d'une arthroplastie totale de la hanche (ATH) ou du genou (ATG). MéTHODE: Nous avons réalisé une étude de cohorte rétrospective de tous les adultes ayant subi une ATH ou une ATG dans notre établissement en extrayant les données de la base de données de notre service de douleur aiguë. Les variables liées au patient, à l'anesthésie, et à la chirurgie et associées à un échec de l'AOCP, défini comme une analgésie inadéquate exigeant la conversion en ACP-IV dans les 24 heures suivant l'ATH ou l'ATG, ont été évaluées. Des analyses de régression logistique univariée et multivariée ont été effectuées pour identifier les prédicteurs d'un échec de l'AOCP. RéSULTATS: Sur les 926 patients ayant subi une ATH ou une ATG (n = 411 et 515, respectivement), l'AOCP n'a pas fonctionné chez 147 (15,9 %) patients (67 patients d'ATH et 80 d'ATG), entraînant une douleur modérée à grave. L'analyse de régression multivariée a montré que les échecs de l'AOCP sont survenus chez les personnes plus jeunes (rapport de cotes ajusté [RCA] par année d'âge, 0,97; IC 99 %, 0,95 à 0,99; P < 0,001), lors d'une utilisation préopératoire chronique d'opioïdes à libération contrôlée (RCA, 3,45; IC 99 %, 1,60 à 7,35; P < 0,001), et lors d'une anesthésie générale vs une rachianesthésie (RCA, 2,86; IC 99 %, 1,20 à 6,84; P = 0,002). CONCLUSION: L'utilisation de l'AOCP procure une analgésie adéquate à la majorité des patients subissant une ATH ou une ATG. Les facteurs prédictifs d'un échec de l'AOCP devraient être pris en considération lors du choix de la principale modalité analgésique après une ATH/ATG.

The Analgesic Efficacy of Transversus Abdominis Plane Block After Bariatric Surgery: a Systematic Review and Meta-analysis with Trial Sequential Analysis.

The transversus abdominis plane (TAP) block has been used to relieve pain after bariatric surgery but with conflicting data on its analgesic efficacy. We conducted this systematic review and meta-analysis with trial sequential analysis to clarify whether TAP block provides effective postoperative analgesia in patients undergoing bariatric surgery. We systematically searched the literature for any trials comparing TAP block with a control group (no block or sham injection). The primary outcome was pain scores at rest (analog scale, 0-10) at 2 postoperative hours. Secondary pain-related outcomes included pain scores at rest at 12 and 24 h and both dynamic pain scores and intravenous morphine equivalent consumption at 2, 12 and 24 h. Additional secondary outcomes sought were rates of postoperative infection, haematoma, visceral injury and local anaesthetic systemic toxicity. Thirteen trials totalling 1025 patients were identified. Pain scores at rest at 2 postoperative hours were significantly lower in the TAP block group compared with the control group, with a mean (95% CI) difference of - 1.8 (- 2.5, - 1.1); I2 = 85%; p < 0.00001. All other secondary pain-related outcomes were also significantly lower in the intervention group with the exception of dynamic pain scores and intravenous morphine equivalent consumption at 2 postoperative hours. Rates of block-related complications were not significantly different between groups. The overall quality of evidence was moderate-to-low. There is moderate-to-low level evidence that the TAP block improves postoperative analgesia after bariatric surgery up to 24 postoperative hours, when compared with a control group, without major reported complications. Clinical Trial NumberPROSPERO - registration number: CRD42019136542.

Interscalene brachial plexus block for surgical repair of clavicle fracture: a matched case-controlled study.

BACKGROUND: Innervation of the clavicle is complex and debated, with scarce data on the analgesic and clinical impact of regional anaesthesia after surgical repair of clavicle fracture. METHODS: In order to assess the analgesic efficiency of an interscalene brachial plexus block (ISB) for surgical repair of clavicle fracture, 50 consecutive patients scheduled for surgical fixation of middle/lateral clavicle fracture under general anaesthesia with ISB were prospectively enrolled. This cohort was compared to a historical control of 76 retrospective patients without regional block. The primary outcome was total intravenous morphine equivalent consumption at 2 postoperative hours. To assess the ISB impact, both an overall cohort analysis and a case-matched analysis with each ISB-treated patient matched to a Non-ISB-treated patient was performed. Matching employed a 1-to-1, nearest-neighbour approach using the Mahalanobis metric. RESULTS: In the overall cohort, patients with ISB had significantly lower i.v. morphine equivalent consumption at 2 postoperative hours (0.7 mg (95% CI 0.1 to 1.2) versus controls 8.8 mg (95% CI 7.1 to 10.4); P <  0.0001). These results persisted after case-matching the cohorts (mean difference for the primary outcome: 8.3 mg (95% CI 6.5 to 10.0); P <  0.001). CONCLUSIONS: ISB provides effective analgesia after surgical fixation of middle and lateral clavicle fracture. These results should help physicians in establishing an analgesic strategy for this type of surgery. Further research is needed to identify the optimal regional technique for medial third clavicle fractures and the clinically relevant contributions of the cervical and brachial plexus. TRIAL REGISTRATION: Clinicaltrials.gov - NCT02565342, October 1st 2015.

De-implementing wisely: developing the evidence base to reduce low-value care.

Choosing Wisely (CW) campaigns globally have focused attention on the need to reduce low-value care, which can represent up to 30% of the costs of healthcare. Despite early enthusiasm for the CW initiative, few large-scale changes in rates of low-value care have been reported since the launch of these campaigns. Recent commentaries suggest that the focus of the campaign should be on implementation of evidence-based strategies to effectively reduce low-value care. This paper describes the Choosing Wisely De-Implementation Framework (CWDIF), a novel framework that builds on previous work in the field of implementation science and proposes a comprehensive approach to systematically reduce low-value care in both hospital and community settings and advance the science of de-implementation.The CWDIF consists of five phases: Phase 0, identification of potential areas of low-value healthcare; Phase 1, identification of local priorities for implementation of CW recommendations; Phase 2, identification of barriers to implementing CW recommendations and potential interventions to overcome these; Phase 3, rigorous evaluations of CW implementation programmes; Phase 4, spread of effective CW implementation programmes. We provide a worked example of applying the CWDIF to develop and evaluate an implementation programme to reduce unnecessary preoperative testing in healthy patients undergoing low-risk surgeries and to further develop the evidence base to reduce low-value care.

Low- versus high-dose intraoperative opioids: A systematic review with meta-analyses and trial sequential analyses.

BACKGROUND: Opioid-induced hyperalgesia is a state of nociceptive sensitisation secondary to opioid administration. The objective of this meta-analysis was to test the hypothesis that high-dose intraoperative opioids contribute to increased post-operative pain and hyperalgesia when compared with a low-dose regimen in patients under general anaesthesia. METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement guidelines and rated the certainty of evidence with the Grading of Recommendations, Assessment, Development and Evaluation system. Only trials investigating pain outcomes and comparing two different dosages of the same intraoperative opioid in patients under general anaesthesia were included. The primary outcome was pain score (analogue scale, 0-10) at 24 post-operative hours. Secondary outcomes included pain score and cumulative intravenous morphine equivalents (mg) consumed at 2 post-operative hours, together with mechanical pain threshold (g·mm-2 ). RESULTS: Twenty-seven randomised controlled trials, including 1630 patients, were identified. Pain score at rest at 24 post-operative hours was increased in the high-dose group (mean difference [95% CI]: -0.2 [-0.4, -0.1]; trial sequential analysis-adjusted CI: -0.4, -0.02; low certainty of evidence). Similarly, at 2 post-operative hours, both pain score (mean difference [95% CI]: -0.4 [-0.6, -0.2]; low certainty of evidence) and cumulative intravenous morphine equivalents consumed (mean difference [95% CI]: -1.6 mg [-2.6, -0.7]; low certainty of evidence) were significantly higher in the high-dose group. Finally, the threshold for mechanical pain was significantly lower in the high-dose group (mean difference to pressure [95% CI]: 3.8 g·mm-2 [1.8, 5.8]; low certainty of evidence). CONCLUSIONS: There is low certainty of evidence that high-dose intraoperative opioid administration increases pain scores in the post-operative period, when compared with a low-dose regimen.

Practice advisory on the bleeding risks for peripheral nerve and interfascial plane blockade: evidence review and expert consensus.

The risk of bleeding complications during regional anesthesia procedures is a significant patient safety consideration. Nevertheless, existing literature provides limited guidance on the stratification of bleeding risk for peripheral nerve and newly described interfascial plane blocks. Our objective was to produce an evidence-based consensus advisory that classifies bleeding risks in patients undergoing regional peripheral nerve and interfascial plane block procedures. This advisory is intended to facilitate clinical decision-making in conjunction with national or local guidelines and to guide consideration for appropriate alterations to anticoagulation regimens before specific regional anesthesia procedures. In pursuit of this goal, the Regional Anesthesia and Acute Pain Section of the Canadian Anesthesiologists Society (CAS) assembled a panel of seven Canadian experts to classify the risk of bleeding complications associated with regional peripheral nerve and interfascial plane blocks. At the 75th annual meeting of the CAS in June 2018, the panel's expert opinion was finalized and the published literature was quantified within an organized framework. All common peripheral nerve and interfascial plane blocks were categorized into "low risk", "intermediate risk", and "high risk" based on the literature evidence, bleeding risk scores, and consensus opinion (in that order of priority). Clinical data is often limited, so readers of this consensus report should be reminded that these recommendations are mostly based on expert consensus. Hence, this advisory should not to be defined as a standard of care but rather serve as a resource for clinicians assessing the risk and benefits of regional anesthesia in management of their patients.

Measuring the frequency and variation of unnecessary care across Canada.

BACKGROUND: Through the Choosing Wisely Canada (CWC) campaign, national medical specialty societies have released hundreds of recommendations against health care services that are unnecessary, i.e. present little to no benefit or cause avoidable harm. Despite growing interest in unnecessary care both within Canada and internationally, prior research has typically avoided taking a national or even multi-jurisdictional approach in measuring the extent of the issue. This study estimates use of three unnecessary services identified by CWC recommendations across multiple Canadian jurisdictions. METHODS: Two retrospective cohort studies were conducted using administrative health care data collected between fiscal years 2011/12 and 2012/13 to respectively quantify use of 1) diagnostic imaging (spinal X-ray, CT or MRI) among Albertan patients following a visit for lower back pain and 2) cardiac tests (electrocardiogram, chest X-ray, stress test, or transthoracic echocardiogram) prior to low-risk surgical procedures in Alberta, Saskatchewan, and Ontario. A cross-sectional study of the 2012 Canadian Community Health Survey was also conducted to estimate 3) the proportion of females aged 40-49 that reported having a routine mammogram in the past two years. RESULTS: Use of unnecessary care was relatively frequent across all three services and jurisdiction measured: 30.7% of Albertan patients had diagnostic imaging within six months of their initial visit for lower back pain; a cardiac test preceded 17.9 to 35.5% of low-risk surgical procedures across Alberta, Saskatchewan, and Ontario; and 22.2% of Canadian women aged 40-49 at average-risk for breast cancer reported having a routine screening mammogram in the past two years. CONCLUSIONS: The use of potentially unnecessary care appears to be common in Canada. This investigation provides methodology to facilitate future measurement efforts that may incorporate additional jurisdictions and/or unnecessary services.