Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis.

BACKGROUND: Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients. METHODS: Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence. RESULTS: We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty. CONCLUSIONS: The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.

Butyrylcholinesterase deficiency and its clinical importance in anaesthesia: a systematic review.

Butyrylcholinesterase deficiency prolongs the effects of the drugs it degrades; succinylcholine and mivacurium. Existing literature on butyrylcholinesterase deficiency is dominated by genetic and biochemical studies. We searched MEDLINE, Embase, Web of Science and Biosis to systematically review the causes and clinical consequences of butyrylcholinesterase deficiency. We considered outcomes clinically relevant if neuromuscular blockade, induced by succinylcholine or mivacurium, was assessed using clinical criteria or neuromuscular monitoring. We included 66 studies: 25 randomised controlled trials; 13 clinically controlled trials; 26 prospective observational studies; 1 retrospective study; and 1 qualitative study. Data heterogeneity precluded quantitative synthesis. Studies described genetic, physiological, acquired or pharmacologically induced causes of butyrylcholinesterase deficiency. The prolongation of neuromuscular blockade by butyrylcholinesterase deficiency was most pronounced with homozygosity of a genetic variant, but other more common factors included increasing age, pregnancy, severe liver disease, burn injuries and drug interactions.

Urgency of caesarean section, grading, alarm chain and intrauterine resuscitation - a survey of Scandinavian practice.

BACKGROUND: About 40,000 women have caesarean section in Scandinavia each year. Organizational factors for emergency caesarean section (CS), classification, anaesthetic practice, alarm chain, intrauterine resuscitation has all been investigated in the United Kingdom, but no information from the Scandinavian countries exists. METHODS: Using publicly available data from the National Board of Health, obstetric anaesthetic departments were identified. The heads of the departments provided e-mail contact details of two anaesthesiologists regularly practicing obstetric anaesthesia who were then surveyed. RESULTS: One hundred and forty-five specialists from 82 departments in Scandinavia replied to our survey. Ninety-five percent of Danish specialists reported a three-grade classification system for urgency CS. Where classification in Denmark was enumerative classification, Norwegians equally reported enumerative and verbal descriptors, whereas Swedish specialists mostly reported verbal descriptors. Local guidelines describing decision-to-delivery interval for emergency CS was reported by 100% of Danish specialists vs. 47% from Norway and 85% from Sweden. Mean benchmark decision-to-delivery interval for emergency CS was 12.7 min. General anaesthesia for emergency CS was highly favoured in Norway (95%) and Sweden (97%), compared to Denmark (49%). Twenty specialists reported existence of local guidelines for intrauterine resuscitation. CONCLUSION: Our survey of Scandinavian specialists indicate emergency CS practise differs from United Kingdom practices in several aspects; general anaesthesia is by the majority of Scandinavian specialists reported as the default choice for emergency CS and benchmark for decision-to-delivery interval is < 20 min. Nomenclature used for classification showed considerable variance in Norway and Sweden compared to Denmark. No joint Scandinavian guidelines exist.

Persistent postsurgical pain after video-assisted thoracic surgery--an observational study.

BACKGROUND: The risk of persistent postsurgical pain (PPP) and subsequent pain-related functional impairment may potentially be reduced by video-assisted thoracic surgery (VATS) compared to thoracotomy. The aim of the study was therefore to assess in detail the incidence and consequences on activities of daily living of PPP after VATS. METHODS: Using a prospective observational design, 47 patients undergoing VATS completed both preoperative, early postoperative and 3 months follow-up. Preoperative pain, pain characteristics, psychological factors, pain-related functional impairment and quantitative sensory testing (QST) including nociceptive thresholds were compared with postoperative data. RESULTS: Only five (11%) patients developed PPP with NRS > 3 originating from the surgical area. However, about 30% of patients still reported some pain-related functional impairment from the surgical area within four well-defined domains of everyday activities. Psychological and sensory thermal tests did not predict persistent postoperative pain, except preoperative pin-prick sensitivity was higher in patients with PPP. Postoperative pain 7 days after surgery was significantly higher in PPP patients. Preoperative pain originating from remote areas did not predict PPP. CONCLUSION: The incidence of PPP, nerve damage (based on QST) and pain-related functional impairment following VATS was lower than reported following thoracotomy. No psychological or other factors predicted PPP. These findings call for further large-scale studies to support VATS to decrease PPP.

The extension of epidural blockade for emergency caesarean section: a survey of Scandinavian practice.

BACKGROUND: Little is known about drugs and safety precautions used during epidural top-ups for emergency caesarean section in Scandinavia. We surveyed Scandinavian practice of epidural top-up regimens for emergency caesarean sections. METHODS: Anaesthetic departments in Denmark, Norway and Sweden were identified via National Boards of Health. An electronic questionnaire was sent to Scandinavian specialist anaesthesiologists performing obstetric anaesthesia asking for information on anaesthetic practice for emergency caesarean section. RESULTS: The response rate was 80% (n=145). One hundred and twenty (83%) specialists reported the existence of local guidelines for epidural top-ups. Fourteen (9.7%) specialists gave a full-dose top-up in the delivery room, 34 (23.4%) initiated the top-up with a test-dose, and 87 (60%) only administered local anaesthetics in the operating theatre. Twenty-five different drug combinations for epidural top-ups were reported. Lidocaine was used by 67 (47.9%) and ropivacaine was used by 53 (37.9%). Seventy (50%) specialists added opioid to the top-up, 15 (10.7%) added bicarbonate and 53 (37.9%) supplemented with adrenaline. Median top-up volume ranged from 16 to 19mL for lidocaine, ropivacaine and chloroprocaine. One-hundred-and-eighteen (81%) specialists recommended trainees use the same regimen. Forty (83%) of 48 specialists topping-up in the labour unit had ephedrine readily available. During transport, pulse oximetry was used by nine (19%) and non-invasive blood pressure monitoring by eight (17%). CONCLUSIONS: Epidural top-ups for emergency caesarean section in Scandinavia are used frequently but normally performed in the operating theatre. Drugs used differ greatly between countries and departments although top-up volumes appear similar. During transport, available equipment and drugs were limited. Best practice guidelines and national guidelines present little information on epidural top-ups that could explain the variation found.

Medical care and organisation at the 2012 Roskilde Music Festival: a prospective observational study.

BACKGROUND: Music festivals, with a mix of music, alcohol and camping at the festival site combined with low hygiene, have become an integral part of society and attracts large numbers of guests. Our study was performed in order to increase the very limited knowledge on health-care issues and organisation of major music festivals. METHOD: Pre-defined illness and injury categories were constructed based on categories previously reported from music festivals. We prospectively recorded patient presentations to the Medical Health Care Organisation (MHCO) at the 2012 Roskilde Festival. RESULTS: During 10 days, more than 130,000 guests and volunteers attended the 2012 Roskilde Festival. Ten thousand six hundred thirty patient presentations were registered between the 30th of June and 9th of July 2012 by the MHCO. The majority of patient presentations, 6919, could be handled by first-aid volunteers with different levels of training. The remaining 3473 patient presentations were assessed to require further health-care competencies or additional resources such as prescriptions, medication or suturing. Two hundred thirty-eight patient presentations were triaged to a designated observation area. Two hundred sixty patients were referred to a local hospital, a general practitioner or a dentist. The overall patient presentation rate was 72/1000 attendees, and the transport-to-hospital rate was 1.8/1000 attendees. CONCLUSION: Our study demonstrates that illnesses and injuries are frequent, although mostly minor, in this normally low-risk population consisting of primarily young and healthy guests. However, comparison with other recent events was difficult as only limited data have been published from other music festivals. Future festivals should publish similar data.

Late sensory changes following chest drain insertion during thoracotomy.

BACKGROUND: It is well known that chest drains are associated with severe movement-related acute pain. These noxious stimuli could play a significant role in development and maintenance of persistent post-operative pain. Therefore we studied chest drain sites in post-thoracotomy pain syndrome (PTPS) patients, in regard to pain and sensory dysfunction. METHODS: We quantified thermal and pressure thresholds on both the chest drain side and the contralateral side in 11 PTPS patients and 10 pain-free post-thoracotomy patients 33 months after the thoracotomy. On average, each patient had two chest drains inserted during surgery. RESULTS: At follow up, two patients experienced pain at the chest drain sites, but had maximal pain near or at the thoracotomy scar. Comparison between chest drain side and control side for all 21 patients demonstrated significantly elevated thresholds for warmth detection and heat pain on the chest drain side (P < 0.01), but not for cool detection or pressure. No significant differences between chest drain side and control side were observed within PTPS or pain-free patients. Comparing PTPS and pain-free patients (chest drain-to-control side), no significant differences in thresholds were found. Although all 11 PTPS patients suffered from incisional pain, only two patients had pain from chest drains. CONCLUSION: Increased thresholds for thermal detection suggest that chest drain insertion is associated with late nerve injury. Because no significant differences in sensory thresholds between PTPS and pain-free patients were found, the pathophysiological role of small fibre nerve injury from chest drains in relation to PTPS remains unclear.

Quantitative sensory testing of persistent pain after video-assisted thoracic surgery lobectomy.

BACKGROUND: Video-assisted thoracic surgery (VATS) lobectomy may potentially reduce the risk of post-thoracotomy pain syndrome (PTPS). However, it may still carry a risk of intraoperative nerve damage and thereby development of PTPS. Thus, our aim was to present a detailed long-term neurophysiological characterization of PTPS after VATS. METHODS: Quantitative sensory testing, using thermal and mechanical stimuli, was performed in 13 PTPS patients and 35 pain-free patients recruited 33 months after VATS lobectomy. RESULTS: When comparing the operated side with the control side in PTPS patients, increased thresholds of tactile and warmth detection were observed, while in pain-free patients, increased thresholds of warmth detection, cool detection, and heat pain were demonstrated. At the anterior porthole, pain-free patients displayed increased threshold to thermal detection when compared with the control side. Only side-to-side difference for tactile detection threshold was increased in PTPS patients compared with pain-free patients. Assessment of central sensitization showed no significant differences within or between PTPS and pain-free patients nor did group comparison of area of hypo- and hyperaesthesia to cool. Anxiety and depression scores (HADS) were higher in PTPS patients, but the area of hyper- and hypoaesthesia did not differ significantly between HADS groups. CONCLUSIONS: Increased sensory thresholds suggest nerve injury to be present on the operated side in both PTPS and pain-free patients. However, no significant quantitative differences between PTPS and pain-free patients could be found, implicating the presence of factors other than intercostal nerve injury as important for development of PTPS after VATS lobectomy.

Consequences of persistent pain after lung cancer surgery: a nationwide questionnaire study.

BACKGROUND: post-thoracotomy pain syndrome (PTPS) and its social consequences have been inconsistently investigated as most studies were either small sized, focused on a limited number of risk factors or included heterogeneous surgical procedures. The current objectives were to obtain detailed information on the consequences of PTPS after thoracotomy and video-assisted thoracic surgery (VATS) from homogenous unselected nationwide data, and to suggest mechanisms for the development of PTPS. METHODS: data from 1327 patients were collected using a prospective national database and combined with a detailed questionnaire. RESULTS: the response rate was 81.5%, resulting in 546 patients without prior thoracic surgery for the final analysis. Follow-up was 22 months (range 12-36). PTPS occurred in 33% thoracotomy patients and 25% VATS patients. Clinically relevant pain was present in 11-18% of the patients and severe pain in 4-12% depending on the level of physical activity. In PTPS patients, 64% also had pain from other locations on the body. Perceived sensory changes in the thoracic area were present in 63% of PTPS patients vs. 25% in pain-free patients (P<0.001). When comparing VATS with thoracotomy, no consistent differences in the prevalence, distribution of pain, sensory changes or effect of pain on daily activities were observed although clinically relevant and severe pain was reduced after VATS. CONCLUSIONS: this nationwide study corroborates that PTPS is a clinically relevant problem influencing daily activities a long time after thoracotomy and VATS. Nerve injury and increased pain responsiveness may explain the majority of symptoms, the prevalence and distribution of pain including perceived sensory sensations.