Canadian Journal of Anesthesia-Journal Canadien D Anesthesie最新文献

Purpose: We aimed to identify the neuraxial anesthesia failure rate of de novo single-injection spinal and combined spinal-epidural anesthesia for postpartum tubal ligation at our hospital along with variables associated with neuraxial anesthesia failure.

Methods: We conducted a single-centre retrospective cohort study of patients who underwent a postpartum tubal ligation with de novo single-injection spinal or combined spinal-epidural anesthesia from 1 January 2020 to 31 December 2022 at Baylor Scott & White Medical Center-Temple (Temple, TX, USA). We defined neuraxial anesthesia failure as conversion to general anesthesia involving the use of an endotracheal tube or supraglottic airway, administration of intravenous propofol at doses > 10 mg, intravenous fentanyl > 100 µg, or the use of inhaled nitrous oxide.

Results: During the study period, 243 patients underwent postpartum tubal ligation with single-injection spinal or combined spinal-epidural anesthesia, and 28 (11.5%) had neuraxial anesthesia failure. Using a multivariate logistic regression designed to predict neuraxial anesthesia failure using variables of interest, we found that a 5-min increase in time from spinal anesthesia placement to skin incision was associated with neuraxial anesthetic failure (adjusted odds ratio [aOR], 3.10; 95% confidence interval [CI], 2.01 to 4.79; P < 0.001) along with a 5-min increase in time from skin incision to wound closure (aOR 1.35; 95% CI, 1.10 to 1.66; P = 0.004) CONCLUSION: Patients who underwent postpartum tubal ligation under single-injection spinal or combined spinal epidural anesthesia had a neuraxial failure rate of 11.5%. Time from spinal placement to skin incision and time from skin incision to wound closure were independently associated with neuraxial anesthesia failure.

Purpose: Perioperative gabapentinoids may not provide meaningful analgesia and can have significant adverse events. Our objective was to estimate the association of two electronic health record (EHR) interventions with pregabalin prescribing by the acute pain service (APS) at a multi-site academic health sciences network.

Methods: We conducted a quality improvement initiative using a retrospective observational cohort and a quasi-experimental interrupted time series design. Following a baseline period (19 January 2021-19 January 2022), we introduced a Best Practice Advisory that warned of pregabalin's risks for sedation or respiratory depression. On 19 June 2022, pregabalin was removed as a standard checkbox in the APS orders. The primary outcome was the proportion of patients receiving pregabalin during their APS admission. The balancing measure was the highest postoperative day one pain score. Analysis used segmented regression in an interrupted time series design to estimate the immediate (level) change, trend (slope), and total counterfactual differences, controlling for the preintervention trend.

Results: We included 10,667 patients (5,559 preintervention, 2,271 postintervention 1, and 2,837 postintervention 2). Preintervention, 1,284 APS admissions had a pregabalin order (23.1%) compared with 379 (16.7%) after intervention 1 and 490 (17.3%) after intervention 2. Our interrupted time series analysis did not identify significant immediate, trend, or total counterfactual differences associated with the interventions (intervention 1, total counterfactual P = 0.76; intervention 2, total counterfactual P = 0.11). Only the preintervention trend (-0.2% per week, 95% confidence interval, -0.5 to -0.1) was significantly different (P < 0.001). No changes in pain intensity scores occurred despite decreased pregabalin use over time.

Conclusion: We did not identify a significant association of EHR interventions with pregabalin prescribing. Nevertheless, a continued downtrend in pregabalin prescribing was not associated with worsening acute pain.

Purpose: Postmastectomy breast reconstruction (BR) may be associated with significant postoperative pain. Use of regional anesthetic blocks has been identified as a potentially beneficial technique to reduce perioperative pain. We sought to conduct a pilot feasibility trial to evaluate the addition of interpectoral and pectoserratus blocks to thoracic paravertebral blocks (TPVBs).

Methods: We conducted a pilot feasibility randomized controlled trial (RCT) at the Providence Breast Centre (Mount Saint Joseph's Hospital, Vancouver, BC, Canada), between 7 May 2021 and 17 March 2023. Adult female patients undergoing BR using tissue expanders or implants were randomized (1:1) to receive TPVB + interpectoral and pectoserratus blocks (intervention) or TPVB + saline (control). Feasibility outcomes related to recruitment, retention, block administration, and safety. We also measured numerical rating scale (NRS) pain scores 24 hr postoperatively and assessed whether the lower bound of the 80% confidence interval (CI) for the between-group difference in mean scores was > 0.

Results: Of 83 eligible patients, 30 (36%) were randomized. Average recruitment was 1.3 patients per month; all blocks were successfully administered, and there were no complications associated with the blocks. Retention to the end of follow-up (six months) was 90%. Mean (standard deviation) self-reported NRS pain scores at 24 hr postoperatively were 3.0 (1.9) and 3.5 (1.9) in the control and intervention groups, respectively (difference in means, -0.5; 80% confidence interval, -1.4 to 0.5).

Conclusion: This RCT showed the feasibility and safety of the intervention with a high retention to the end of follow-up. Nevertheless, we did not meet our prespecified recruitment target, and the results did not provide evidence of potential effectiveness of the intervention to sufficiently support the conduct of a definitive efficacy RCT.

Study registration: ClinicalTrials.gov ( NCT04860843 ); first posted 27 April 2021.

Purpose: Owing in part to the development and popularization of fascial plane blocks (FPBs), high-volume injection of local anesthetic (LA) is becoming more commonplace. Fascial plane blocks typically use high LA volumes to maximize spread, often pushing towards the maximum recommended dosing. This narrative review summarizes the pharmacokinetic literature for several of the most common FPBs.

Methods: We searched PubMed®, Embase, the Cochrane Library, and Google Scholar using the following search terms: (plasma concentration, pharmacokinetics, toxicity, local anesthetic systemic toxicity [LAST]) AND (erector spinae plane, serratus anterior plane, parasternal intercostal plane, quadratus lumborum, transversus abdominis plane, fascia iliaca, pericapsular nerve group), as well as FPB acronyms.

Results: Typical LA dosing in studies used concentrations of ropivacaine 0.25-0.5%, levobupivacaine 0.125-0.25%, and bupivacaine 0.25% at volumes of 20-40 mL. While numerous studies found average LA plasma concentrations well below the established thresholds, several patients crossed the toxic threshold. Patients with LA plasma concentrations above toxic thresholds often did not experience LAST symptoms; nevertheless, there are several reports of mild neurologic symptoms and even seizures.

Conclusions: Diligent care should be taken to avoid LAST in FPBs. We recommend the calculation of weight-based doses, aspiration before injection, incremental dosing, close monitoring, and ultrasound observation of injectate when administering high volumes. Clinicians should consider adding low-dose epinephrine to FPBs. The LA concentration should decrease with increasing volume to ensure that the total dose of LA remains below maximum dosing recommendations. Clinicians should use extra caution in those blocks and with patients at a higher risk for LAST.

Purpose: Epidural analgesia has been considered a highly effective analgesic modality for hepatobiliary surgeries, particularly within 72 hr postoperatively. Coagulation derangements are possible complications following liver resection that can be concerning in the setting of epidural analgesia given the inherent risk of spinal epidural hematoma. We sought to develop predictive models for postoperative coagulation disturbance (defined as an international normalized ratio > 1.5, a partial thromboplastin time > 40 sec, or a platelet count < 100,000 × 10⁶·L^-1) in patients eligible for epidural analgesia.

Methods: We conducted a retrospective cohort study of patients undergoing liver resection at the University of Iowa (Iowa City, IA, USA) between 2011 and 2023. We reviewed records for patient characteristics, operative parameters, preoperative coagulation labs, and postoperative coagulation labs up to seven postoperative days. We used three types of predictive modeling.

Results: Among 684 patients, 37 had a length of stay ≤ 72 hr of surgery or preoperative coagulation disturbance. Among the remaining 647 patients, 512 (79%) received a thoracic epidural. The incidence of postoperative coagulation disturbances within 72 hr was 25% (95% confidence interval, 22 to 28), mostly thrombocytopenia (20% of all patients), and was noted on postoperative day 1 for 11% and postoperative day 2 for 22%. The volume of liver resected was greater among patients with postoperative coagulation disturbance (P < 0.001; area under the receiving operating characteristic curve, 0.61). There was no predictive value for coagulation disturbance based on patients' sex, American Society of Anesthesiologists' Physical Status classification, body mass index, weight, age, adjuvant chemotherapy, estimated operative duration, or year of data (all standardized differences < 0.24). Classification tree modeling had a single node (i.e., no useful preoperative prediction). Stepwise backward logistic regression using P < 0.05 for inclusion had just two patients (0.3%) with a predicted probability of postoperative coagulation disturbance < 10% and none < 5%.

Conclusions: Coagulation disturbances occur commonly in the context of hepatic surgery. Preoperative data commonly used to qualify a patient to receive epidural analgesia are insufficient to predict which patients are likely to develop postoperative coagulation disturbance. Regardless of the predictive modeling or criterion, the postoperative risk of coagulopathic disturbance will exceed 5% by 72 hr postoperatively. Enhanced recovery protocols recommending early epidural catheter removal need to consider the period of incidence of coagulation disturbance.