Lived experiences of transgender and nonbinary people in the perioperative context: a qualitative study.

BACKGROUND: Transgender and nonbinary (TNB) people experience obstacles that create barriers to accessing health care, including stigmatization and health inequities. Our intention was to describe the lived experiences of TNB patients and identify potential gaps in the education of health care professionals. METHODS: We conducted a qualitative descriptive study influenced by phenomenology by interviewing with TNB adults who underwent surgery in Canada within the previous 5 years. We recruited participants using purposeful and snowball sampling via online social networking sites. Audio recordings were transcribed. Two authors coded the transcripts and derived the themes. RESULTS: We interviewed 21 participants, with a median interview duration of 49 minutes. Participants described positive and negative health care encounters that led to stress, confusion, and feelings of vulnerability. Major themes included having to justify their need for health care in the face of structural discrimination; fear and previous traumatic experiences; community as a source of support and information; and the impact of interactions with health care professionals. INTERPRETATION: Participants detailed barriers to accessing care, struggled to participate in shared decision-making, and desired trauma-informed care principles; they described strength in community and positive interactions with health care professionals, although barriers to accessing gender-affirming care often overshadowed other aspects of the perioperative experience. Additional research, increased education for health care professionals, and policy changes are necessary to improve access to competent care for TNB people.

An Innovative Approach to Determine Programmed Intermittent Epidural Bolus Pump Settings for Labor Analgesia: A Randomized Controlled Trial.

BACKGROUND: Three settings are required on a programmed intermittent epidural bolus (PIEB) pump for labor analgesia: the PIEB next bolus (PIEBnb), PIEB interval (PIEBi), and PIEB volume (PIEBv). The ideal settings for these parameters are still unknown. We hypothesized a mathematical modeling tool, response surface methodology (RSM), could estimate 3 PIEB pump parameters while balancing 3 clinically important patient outcomes simultaneously. The study objective was to use RSM to estimate PIEB settings (PIEBnb, PIEBi, and PIEBv) while maximizing maternal satisfaction, minimizing the need for clinician-administered boluses, and optimizing the ratio of delivered/requested patient-controlled epidural analgesia (PCEA) boluses simultaneously. METHODS: With institutional ethics approval, a double-blind randomized trial was completed in a tertiary care labor and delivery center. Nulliparous, English-speaking American Society of Anesthesiologists (ASA) physical status II patients aged 18 to 45 years at full term, single gestation in vertex presentation, in spontaneous labor and ≤7 cm cervical dilation were included. Patients with comorbidities, contraindications to neuraxial analgesia, using chronic analgesics, <152 cm, or body mass index (BMI) >45 kg/m 2 were excluded. After informed consent, labor analgesia was initiated using 10 mL ropivacaine 0.2% with 10 µg/mL fentanyl solution and PCEA (volume 6 mL every 10 minutes). Patients were randomized to predetermined PIEB settings. RSM identified 3 pump settings that represented a stationary point that best maximized or minimized 3 outcomes simultaneously: PCEA ratio (a ratio closest to 1), clinician bolus (optimal is 0), and maternal satisfaction (visual analog scale, 0-100, ideal response is ≥90). RESULTS: Of 287 potential participants, 192 did not meet inclusion criteria or declined to participate, and 26 were withdrawn, leaving 69 patients for study inclusion. Using RSM, the suggested PIEB settings for all the primary study outcomes were as follows: PIEBnb = 29.4 minutes, PIEBi = 59.8 minutes, and PIEBv = 6.2 mL. These PIEB settings corresponded to the following clinical outcomes: maternal satisfaction at 93.9%, PCEA ratio at 0.77, and need for clinician bolus at 0.29. The dermatome sensory score was between T10 and T5 in 89% of the patients. The median lowest Bromage score was 4. CONCLUSIONS: This novel study used a mathematical model to estimate PIEB pump settings while simultaneously maximizing 3 clinical outcomes. Equally weighted clinical outcomes prevent maximal outcome optimization and may not reflect patient priorities. Future studies or quality improvement endeavors could use RSM methodology to estimate PIEB pump settings targeting optimal values for a single clinical outcome of determined importance to parturients.

The Incidence and Predictors of Failed Spinal Anesthesia After Intrathecal Injection of Local Anesthetic for Cesarean Delivery: A Single-Center, 9-Year Retrospective Review.

BACKGROUND: The incidence of failed spinal anesthesia varies widely in the obstetric literature. Although many risk factors have been suggested, their relative predictive value is unknown. The primary objective of this retrospective cohort study was to determine the incidence of failed spinal anesthesia for cesarean deliveries at a tertiary care obstetric hospital, and its secondary objectives were to identify predictors of failed spinal anesthesia in the obstetrics population and quantify their relative importance in a predictive model for failure. METHODS: With local institutional ethics committee approval, a retrospective review of our hospital database identified the incidence of failed spinal anesthesia for 5361 cesarean deliveries between 2010 and 2019. We performed a multivariable analysis to assess the association of predictors with failure and a dominance analysis to assess the importance of each predictor. RESULTS: The incidence of failed spinal anesthesia requiring an alternative anesthetic was 2.1%, with conversion to general anesthesia occurring in 0.7% of surgeries. Supplemental analgesia or sedation was provided to an additional 2.0% of women. The most important predictors of a failed spinal anesthetic were previous cesarean delivery (odds ratio [OR], 11.33; 95% confidence interval [CI], 7.09-18.20; P < .001), concomitant tubal ligation (OR, 8.23; 95% CI, 3.12-19.20; P < .001), lower body mass index (BMI) (kg·m -2 , OR, 0.94; 95% CI, 0.90-0.98; P = .005), and longer surgery duration (minutes, OR, 1.02; 95% CI, 1.01-1.03; P = .006). Previous cesarean delivery was the most significant risk factor, contributing to 9.6% of the total 17% variance predicted by all predictors examined. CONCLUSIONS: Spinal anesthesia failed to provide a pain-free surgery in 4.1% of our cesarean deliveries. Previous cesarean delivery was the most important predictor of spinal failure. Other important predictors included tubal ligation, lower BMI, and longer surgery duration.

The association between labour epidural analgesia and postpartum depression in primiparous patients: a historical cohort study.

PURPOSE: Peripartum pain has been associated with postpartum depression (PPD), and labour epidural analgesia (LEA) may be able to modify this risk. The objective of this historical cohort study was to examine the association between LEA and PPD among primiparous patients. METHODS: With institutional research ethics board approval, a provincial perinatal database was searched for primiparous patients who delivered a liveborn singleton infant between 2004 and 2018. Those patients who experienced PPD following their first delivery were identified by a history of PPD in the perinatal records of their second pregnancy. We used logistic regression to compute odds ratios (ORs) for the association between LEA and PPD and performed an adjusted analysis to control for confounding variables. RESULTS: A total of 35,437 primiparous patients were identified, 67% (n = 23,599) of whom received LEA. In the cohort, 3.7% (n = 1,296) of patients developed PPD. Patients who received LEA had increased odds of developing PPD compared with patients who did not receive LEA (adjusted OR, 1.29; 95% confidence interval [CI], 1.12 to 1.48). In a multivariable regression model, LEA remained a significant predictor for PPD, as did body mass index, pre-existing anxiety, and maternal antidepressant use. CONCLUSION: This historical cohort study found an association between LEA and PPD among primiparous patients who subsequently had a second pregnancy in the same province. The findings call into question the hypothesis that LEA decreases the risk for PPD and further illustrates the complexities of PPD.

RéSUMé: OBJECTIF: La douleur péripartum a été associée à la dépression post-partum (DPP), et l'analgésie péridurale obstétricale (APO) pourrait modifier ce risque. L'objectif de cette étude de cohorte historique était d'examiner l'association entre l'APO et la DPP chez les primipares. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique de la recherche de l'établissement, une base de données périnatale provinciale a été consultée pour trouver des personnes primipares qui ont accouché d'un seul enfant vivant né entre 2004 et 2018. Les primipares qui ont présenté une DPP après leur premier accouchement ont été identifiées par la présence d'antécédents de DPP dans les dossiers périnataux de leur deuxième grossesse. Nous avons utilisé la régression logistique pour calculer les rapports de cotes (RC) pour l'association entre l'APO et la DPP et réalisé une analyse ajustée pour tenir compte des variables de confusion. RéSULTATS: Au total, nous avons identifié 35 437 personnes primipares, dont 67 % (n = 23 599) ont bénéficié d'une APO. Dans la cohorte, 3,7 % (n = 1296) ont manifesté une DPP. Les personnes ayant reçu une APO présentaient un risque accru de développer une DPP par rapport aux primipares qui n'avaient pas reçu d'APO (RC ajusté, 1,29; intervalle de confiance [IC] à 95 %, 1,12 à 1,48). Dans un modèle de régression multivariée, l'APO est restée un prédicteur significatif de DPP, tout comme l'indice de masse corporelle, une anxiété préexistante et l'utilisation maternelle d'antidépresseurs. CONCLUSION: Cette étude de cohorte historique a révélé une association entre l'APO et la DPP chez les personnes primipares qui ont par la suite eu une deuxième grossesse dans la même province. Les résultats remettent en question l'hypothèse selon laquelle l'APO diminue le risque de DPP et illustre davantage les complexités de la DPP.

Pandemic-related factors predicting physician burnout beyond established organizational factors: cross-sectional results from the COPING survey.

The COVID-19 pandemic has increased physician burnout beyond high baseline levels. We aimed to determine whether pandemic-related factors contribute to physician burnout beyond known organizational factors. This was a cross-sectional survey of Canadian physicians using a convenience sample. Eligible participants included any physician currently holding a license to practice in Canada. Responses were gathered from May 13 to 12 June 2020. Risk factors measured included the newly developed Pandemic Experiences and Perceptions Scale (PEPS) subscales, contact with virus, pandemic preparation, and provincial caseload. The primary outcome was the Maslach Burnout Inventory (MBI). The primary outcome was completed by 309 respondents. Latent profile analysis found 107 (34.6%) respondents were burned out. In multivariate analysis, exhaustion was independently associated with PEPS adequacy, risk perception, and worklife subscales (adjusted R2 = 0.236, P < 0.001). Cynicism was associated with exhaustion, and PEPS worklife (adjusted R2 = 0.543, P < 0.001). Efficacy was associated with cynicism, PEPS worklife, and active cases (adjusted R2 = 0.152, P < 0.001). Structural equation modelling showed statistically significant direct paths between PEPS areas of worklife and all MBI subscales. Contact with virus, preparation, and PEPS risk perception added to the prediction of MBI exhaustion. Among a sample of Canadian physicians during the COVID-19 pandemic, adequacy of resources, risk perception, and quality of worklife were associated with burnout indices. To mitigate physician burnout organizations should work to improve working conditions, ensure adequate resources, and foster perceived control of risk of transmission.Trial Registration: NCT04379063.

Perioperative mobile application for mothers undergoing Cesarean delivery: a prospective cohort study on patient engagement.

PURPOSE: Giving birth is the most common reason for hospital admission, with Cesarean delivery being the most frequently performed inpatient surgery. Through a needs assessment and iterative design process involving patients and obstetric anesthesiologists, we previously developed a mobile application, C-Care, for patients undergoing Cesarean delivery. The focus of C-Care is perioperative education and self-monitoring of potential anesthetic complications. This study aimed to obtain feedback on patient engagement with C-Care. METHOD: We conducted a prospective cohort study of patients ≥ 18 yr (n = 36) undergoing elective Cesarean delivery. Anonymous usage data were recorded for 30 days. On postoperative days 1-5, participants received daily self-monitoring questionnaires within C-Care. Fourteen days after surgery, participants received an online survey regarding satisfaction and use of C-Care. RESULTS: Thirty-five out of 36 participants visited the application after orientation, with a median [interquartile range (IQR)] age of 32 [31-36] yr. Each participant visited the application a median of 15 [9-31] times over 30 days and completed a median of 3 [2-4] out of five self-monitoring questionnaires. Each participant viewed a median of 4 [2-7] out of eight education topics, with the most viewed patient education topics being "Controlling Pain" and "The First Few Days". Visits to the application were highest in the first week postpartum. Of the 18 respondents who completed the day 14 survey, 83% (n = 15) participants would recommend C-Care to other women, and the median participant satisfaction score was 7.5 out of 10 (range, 2-10). CONCLUSION: Most participants used this mobile application for patient education and self-monitoring after elective Cesarean delivery. Insights into patient engagement with C-Care after Cesarean delivery could help design more effective perioperative mobile telehealth programs. TRIAL REGISTRATION: www.ClinicalTrials.gov (NCT03746678); registered 5 November 2018.

RéSUMé: OBJECTIF: L'accouchement est la raison la plus courante d'admission à l'hôpital, et l'accouchement par césarienne constitue la chirurgie hospitalière la plus fréquemment pratiquée. Grâce à une évaluation des besoins et un processus de conception itérative impliquant des patientes et des anesthésiologistes obstétricaux, nous avions mis au point une application mobile baptisée C-Care destinée aux patientes subissant un accouchement par césarienne. L'application C-Care a pour but d'être un outil d'éducation périopératoire et d'autosurveillance des complications anesthésiques potentielles. Cette étude visait à obtenir des commentaires de rétroaction sur l'intérêt des patientes pour l'application C-Care. MéTHODE: Nous avons mené une étude de cohorte prospective auprès de patientes ≥ 18 ans (n = 36) subissant un accouchement par césarienne programmée. Des données d'utilisation anonymes ont été enregistrées pendant 30 jours. Les jours postopératoires 1-5, les participantes ont reçu des questionnaires quotidiens d'autosurveillance dans l'application C-Care. Quatorze jours après la chirurgie, les participantes ont reçu un sondage en ligne sur leur satisfaction et leur utilisation de C-Care. RéSULTATS: Trente-cinq des 36 participantes, d'un âge médian [écart interquartile (ÉIQ)] de 32 ans [31-36], ont consulté l'application après leur formation initiale. Chaque participante a consulté l'application 15 [9-31] fois en moyenne sur 30 jours et a rempli en moyenne 3 [2-4] questionnaires d'autosurveillance sur cinq. Chaque participante a consulté en moyenne 4 [2-7] des huit sujets de formation, les sujets les plus consultés étant « Le contrôle de la douleur ¼ et « Les premiers jours ¼. Les consultations de l'application ont été les plus élevées au cours de la première semaine post-partum. Parmi les 18 répondantes qui ont complété le sondage du jour 14, 83 % (n = 15) des participantes recommanderaient C-Care à d'autres femmes, et le score médian de satisfaction des participantes était de 7,5 sur 10 (fourchette, 2-10). CONCLUSION: La plupart des participantes ont utilisé cette application mobile destinée à l'éducation des patientes et à l'autosurveillance après un accouchement par césarienne programmée. Une compréhension de l'intérêt des patientes pour C-Care après un accouchement par césarienne pourrait permettre la conception d'applications mobiles périopératoires plus efficaces. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03746678); enregistrée le 5 novembre 2018.

The association between labour epidural analgesia and postpartum depressive symptoms: a longitudinal cohort study.

BACKGROUND: Pain is a risk factor for postpartum depression (PPD) and labour epidural analgesia (LEA) may lower the incidence of PPD. We evaluated depressive symptoms risk at three, six, and 12 months postpartum in women with LEA compared with women without LEA. METHODS: With ethics approval, hypotheses were tested using data from a longitudinal prospective observational cohort study between January 2015 and January 2019 in nulliparous women aged ≥ 18 yr with uncomplicated, singleton pregnancies. Email surveys were completed at baseline (18-20 weeks' gestation) and at three-, six- and 12 months postpartum, including the Edinburgh Postpartum Depression Scale (EPDS). Maternal, infant, and anesthesia characteristics were abstracted from electronic databases. The EPDS scores at three, six, and 12 months postpartum were analyzed using generalized estimating equations with and without covariates. RESULTS: Of the 909 women who consented to participate, 709 women were included in the study. Antenatal EPDS scores, not LEA, predicted postpartum depressive symptom risk (P < 0.001). The adjusted 95% confidence intervals suggest mean EPDS scores differ from 1.0 point lower in the LEA group at 12 months to 1.5 points higher in the no LEA group at three months on its 0-30 scale. All the confidence intervals included zero at three, six, and 12 months, so were considered non-significant (P > 0.05). CONCLUSION: This study did not identify an association between LEA and risk of depressive symptoms postpartum, although small mean differences between groups cannot be ruled out. Future studies should focus on other modifiable variables that influence the development of PPD.

RéSUMé: CONTEXTE: La douleur constitue un facteur de risque de dépression post-partum (DPP) et l'analgésie péridurale obstétricale (APO) pourrait réduire l'incidence de DPP. Nous avons évalué le risque de symptômes de dépression à trois, six, et 12 mois post-partum chez les femmes ayant reçu une APO comparativement aux femmes sans APO. MéTHODE: Après avoir obtenu l'approbation du comité d'éthique, l'hypothèse a été testée en se fondant sur les données d'une étude de cohorte observationnelle prospective longitudinale réalisée entre janvier 2015 et janvier 2019 auprès des femmes nullipares âgées de ≥ 18 ans avec des grossesses simples et sans complication. Des sondages électroniques ont été complétés au début de l'étude (données de base, 18 à 20 semaines de grossesse), puis à trois, six et douze mois post-partum, et incluaient l'Échelle de dépression postnatale d'Édimbourg (EPDS). Les caractéristiques maternelles, infantiles et anesthésiques ont été extraites des bases de données électroniques. Les scores sur l'EPDS à trois, six, et 12 mois post-partum ont été analysés utilisant des équations d'estimation généralisées avec et sans covariables. RéSULTATS: Parmi les 909 femmes qui ont consenti à participer, 709 femmes ont été incluses dans l'étude. Les scores prénataux sur l'EPDS, et non l'APO, ont prédit le risque de symptômes de dépression post-partum (P < 0,001). Les intervalles de confiance ajustés de 95 % suggèrent que les scores moyens sur l'EPDS différaient de 1,0 point de moins dans le groupe APO à 12 mois à 1,5 point de plus dans le groupe sans APO à trois mois sur l'échelle de 0 à 30. Tous les intervalles de confiance englobaient le zéro à trois, six et 12 mois, et ont donc été considérés comme non significatifs (P > 0,05). CONCLUSION: Cette étude n'a pas identifié d'association entre l'APO et le risque de symptômes dépressifs post-partum, bien que de petites différences moyennes entre les groupes ne puissent être exclues. Les études futures devraient se concentrer sur d'autres variables modifiables qui influencent l'apparition de la DPP.

Pharmacologic labour analgesia and its relationship to postpartum psychiatric disorders: a scoping review.

PURPOSE: This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research. SOURCES: PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above. PRINCIPAL FINDINGS: Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective. CONCLUSIONS: Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.

RéSUMé: OBJECTIF: Cette étude exploratoire avait pour objectif de résumer la littérature actuelle portant sur les troubles psychiatriques postpartum (par ex., dépression postpartum, anxiété postpartum, état de stress post-traumatique postpartum) et la relation possible de ces troubles avec l'utilisation d'une analgésie pharmacologique pour le travail obstétrical (par ex., analgésie péridurale, protoxyde d'azote, opioïdes parentéraux) afin d'identifier les lacunes dans nos connaissances qui pourraient aiguiller la planification de futures recherches. SOURCES: Des recherches ont été effectuées dans les bases de données PubMed, PsycINFO, CINAHL et EMBASE de leur création jusqu'au 9 novembre 2018 afin d'en extraire les études incluant des informations concernant l'analgésie du travail et les troubles psychiatriques postpartum spécifiés ci-dessus. CONSTATATIONS PRINCIPALES: Deux évaluateurs ont passé en revue les études et extrait les données. Parmi les 990 citations identifiées, 17 études ont été incluses pour analyse. Les études existantes ont de petites tailles d'échantillon et sont conçues comme des cohortes observationnelles. Les facteurs de risque psychiatrique des patientes, le mode d'accouchement et le type d'analgésie reçue pour le travail n'étaient pas uniformes d'une étude à l'autre. La plupart des études s'appuyaient sur des tests de dépistage pour poser un diagnostic de maladie psychiatrique postpartum et n'évaluaient pas l'impact de l'analgésie du travail sur la maladie psychiatrique postpartum comme critère d'évaluation principal. CONCLUSION: Les études futures devraient corréler les résultats positifs au dépistage à un diagnostic clinique; envisager d'ajuster le moment de dépistage afin d'inclure la période antepartum ainsi que les périodes du postpartum initial et tardif; et tenir compte du degré de soulagement de la douleur du travail ainsi que de l'analgésie pharmacologique spécifique utilisée pour le travail lors de l'évaluation des troubles psychiatriques postpartum.

An interpretive phenomenological analysis of formative feedback in anesthesia training: the residents' perspective.

BACKGROUND: Consistent formative feedback is cornerstone to competency-by-design programs and evidence-based approaches to teaching and learning processes. There has been no published research investigating feedback from residents' perspectives. We explored the value residents place on feedback in routine operating room settings, their experiences, and understanding of the role of feedback in their training and developing professional identity. METHODS: Interpretive phenomenological analysis of residents' experiences with feedback received in clinical settings involved two focus groups with 14 anesthesia residents at two time points. Analysis was completed in the context of a teaching hospital adapting to new practices to align with nationally mandated clinical competencies. Focus group conversations were transcribed and interpreted through the lens of a social constructivist approach to learning as a dynamic inter- and intra-personal process, and evidence-based assessment standards set by the International Test Commission (ITC). RESULTS: Residents described high quality feedback as consistent, effortful, understanding of residents' thought processes, and containing actionable advice for improvement. These qualities of effective evaluation were equally imperative for informal and formal evaluations. Residents commented that highest quality feedback was received informally, and formal evaluations often lacked what they needed for their professional development. CONCLUSION: Residents have a deep sense of what promotes their learning. Structured feedback tools were seen positively, although the most important determinants of their impact were faculty feedback- and broader evaluation-skills and motivations for both formal and informal feedback loops.

The impact of analgesic intervention during the second stage of labour: a retrospective cohort study.

PURPOSE: The incidence of epidural top-ups received in the second stage of labour in nulliparous women and the obstetrical and neonatal implications associated with these boluses are explored in this retrospective observational study. We hypothesized that an epidural top-up in the second stage of labour reduces operative deliveries by resolving inadequate analgesia. METHODS: A population-based cohort analysis was performed using perinatal data from 1 January 2013 through 31 December 2014. An anesthesia database provided information to determine the top-up incidence. Women with or without a top-up for second-stage duration were compared for method of delivery and neonatal characteristics using descriptive statistics. Logistic regression identified predictive factors for method of delivery. RESULTS: Of the 1,462 women with a second stage of labour > one hour who received epidural analgesia, 105 (7%) required a top-up during the second stage of labour. Women who received a top-up were more likely to have had induction of labour and/or augmentation (89% vs 76%; odds ratio [OR], 2.43; 95% confidence interval [CI], 1.32 to 4.49; P = 0.003), a longer second stage (303 min vs 171 min; mean difference, 132 min; 95% CI, 113 to 151; P < 0.001), and more assisted vaginal (41% vs 17%; OR, 3.35; 95% CI, 2.21 to 5.1; P < 0.001) or Cesarean deliveries (26% vs 11%; OR, 3.04; 95% CI, 1.91 to 4.8; P < 0.001) than women without a top-up. CONCLUSION: Most women who received a top-up had a vaginal (spontaneous or assisted) delivery. Compared with women without a top-up, women requiring a top-up had more predictors of difficult labour and higher rates of assisted vaginal delivery and Cesarean delivery.

Anesthesia and analgesia for gynecological surgery.

PURPOSE OF REVIEW: High-quality analgesia has been linked to improved patient satisfaction as well as improved short-term and long-term postoperative outcomes. Acute surgical pain is a modifiable risk factor for development of chronic postoperative pain, which is reported by up to 26% of gynecologic surgical patients. In other surgical populations, multimodal analgesia has shown improved pain control and decreased reliance on opioids. This review examines recent evidence for various analgesic modalities applied specifically to the gynecologic surgical population. RECENT FINDINGS: Nonopioid agents like acetaminophen, nonsteroidal anti-inflammatories, and gamma-aminobutyric acid analogs resulted in reduction in postoperative pain and opioid consumption. Application of regional anesthetic techniques had a favorable effect that persisted beyond the immediate recovery period. Preemptive analgesia remains unproven. The best evidence for effective combinations comes from ERAS studies that incorporated multimodal analgesia into a systemic approach geared towards early discharge. SUMMARY: Multimodal analgesia had demonstrated advantages for all types of gynecological surgeries in terms of improving postoperative pain control and minimizing opioid-related adverse effects. Multimodal analgesia includes acetaminophen, NSAIDS, and gamma-aminobutyric acid analogs combined with intraoperative nonopioid analgesics such as ketamine, regional anesthesia or intrathecal morphine. Further research should focus on determining most effective combinations and doses of multimodal analgesia.

Prevalence and Predictors of Chronic Pain in Pregnancy and Postpartum.

OBJECTIVE: A clinically relevant number of patients report pain 1 year after vaginal delivery or Caesarean delivery. Study objectives were to identify the incidence of peripartum pain; determine whether pre-existing pain, pregnancy pain, or pain 2 weeks postpartum predicts pain at 3 months; and to identify whether delivery mode, epidural analgesia use, or delivery complications predict non-genito-pelvic pain postpartum. METHODS: Primiparous women at 30 to 36 weeks GA with an uncomplicated singleton pregnancy were recruited from a large perinatal clinic. Participants completed questionnaires on sociodemographics and non-genito-pelvic pain. Questionnaires were completed in the perinatal clinic and then electronically 2 weeks and 3 months postpartum. RESULTS: Of the 133 women included, 50 patients (38%) had a chronic pain condition or pain prior to pregnancy, whereas 73 patients (55%) reported pain in pregnancy. Pain was present 2 weeks postpartum in 57 patients (43%) and 3 months postpartum in 33 patients (25%). Patients with pre-existing pain were more likely to experience pain 2 weeks postpartum (P = 0.006), and patients with pain 2 weeks postpartum were more likely to have pain 3 months postpartum (P = 0.005). Women who had a Caesarean delivery (P < 0.001) were more likely to have non-genito-pelvic pain at 2 weeks but not 3 months postpartum. CONCLUSIONS: Women with pain 2 weeks postpartum were significantly more likely to have pain at 3 months. Further investigation is required to determine whether pre-existing pain, pain in pregnancy, or pain at 2 weeks postpartum can adequately predict the likelihood of chronic pain.

Prevention of persistent pain with lidocaine infusions in breast cancer surgery (PLAN): study protocol for a multicenter randomized controlled trial.

BACKGROUND: Persistent pain is a common yet debilitating complication after breast cancer surgery. Given the pervasive effects of this pain disorder on the patient and healthcare system, post-mastectomy pain syndrome (PMPS) is becoming a larger population health problem, especially as the prognosis and survivorship of breast cancer increases. Interventions that prevent persistent pain after breast surgery are needed to improve the quality of life of breast cancer survivors. An intraoperative intravenous lidocaine infusion has emerged as a potential intervention to decrease the incidence of PMPS. We aim to determine the definitive effects of this intervention in patients undergoing breast cancer surgery. METHODS: PLAN will be a multicenter, parallel-group, blinded, 1:1 randomized, placebo-controlled trial of 1,602 patients undergoing breast cancer surgery. Adult patients scheduled for a lumpectomy or mastectomy will be randomized to receive an intravenous 2% lidocaine bolus of 1.5 mg/kg with induction of anesthesia, followed by a 2.0 mg/kg/h infusion until the end of surgery, or placebo solution (normal saline) at the same volume. The primary outcome will be the incidence of persistent pain at 3 months. Secondary outcomes include the incidence of pain and opioid consumption at 1 h, 1-3 days, and 12 months after surgery, as well as emotional, physical, and functional parameters, and cost-effectiveness. DISCUSSION: This trial aims to provide definitive evidence on an intervention that could potentially prevent persistent pain after breast cancer surgery. If this trial is successful, lidocaine infusion would be integrated as standard of care in breast cancer management. This inexpensive, widely available, and easily administered intervention has the potential to reduce pain and suffering in an already afflicted patient population, decrease the substantial costs of chronic pain management, potentially decrease opioid use, and improve the quality of life in patients. TRIAL REGISTRATION: This trial has been registered on clinicaltrials.gov (NCT04874038, Dr. James Khan. Date of registration: May 5, 2021).

Patient Preferences for Outcomes Associated With Labor Epidural Analgesia.

Purpose Patient preferences for labor epidural analgesia (LEA) have been incompletely evaluated. This study aimed to determine the importance of various LEA outcomes to both antenatal and postpartum patients. Methods This was a cross-sectional study approved by the institutional ethics board. Questionnaires were distributed to two separate and distinct cohorts screened for eligibility: pregnant patients at an antenatal visit and postpartum patients during childbirth admission. A list of common LEA outcomes was compiled using research published in leading anesthesia journals. Participants ranked the outcomes according to perceived importance. They assigned each a number from 1 to 10 (priority ranking; 1 indicated the highest priority outcome and 10 the least). They were also asked to 'spend' $100 towards the outcomes (relative value scale), allocating more money to outcomes more important to them. Results Two hundred twenty questionnaires were completed (105 antenatal, 115 postpartum). 'Achieving desired pain relief' was the most important outcome for both cohorts. It was valued more by the postpartum cohort (Median $50 (25 - 60) vs $30 (18 - 50)). 'Overall satisfaction with the pain management,' 'experiencing a short time to achieve pain relief,' and 'experiencing a short duration of labor' received more money than avoiding various LEA-related side effects. The postpartum cohort ranked 'experiencing a short time to achieve pain relief' as more important than the antenatal cohort (Median 5 (3 - 7) vs 3 (2 - 5)). Conclusions Achieving the desired pain relief was the highest LEA outcome preference for both antenatal and postpartum patients. Avoiding side effects was less important relative to pain-related outcomes.