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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 vsspinal 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.

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 75thannual 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.

Supplemental Digital Content is available in the text.Published ahead of print September 14, 2017.

Published ahead of print September 22, 2015

Background:There is concern about increasing utilization of low-value health care services, including preoperative testing for low-risk surgical procedures. We investigated temporal trends, explanatory factors, and institutional and regional variation in the utilization of testing before low-risk procedures.Methods:For this retrospective cohort study, we accessed linked population-based administrative databases from Ontario, Canada. A cohort of 1 546 223 patients 18 years or older underwent a total of 2 224 070 low-risk procedures, including endoscopy and ophthalmologic surgery, from Apr. 1, 2008, to Mar. 31, 2013, at 137 institutions in 14 health regions. We used hierarchical logistic regression models to assess patient- and institution-level factors associated with electrocardiography (ECG), transthoracic echocardiography, cardiac stress test or chest radiography within 60 days before the procedure.Results:Endoscopy, ophthalmologic surgery and other low-risk procedures accounted for 40.1%, 34.2% and 25.7% of procedures, respectively. ECG and chest radiography were conducted before 31.0% (95% confidence interval [CI] 30.9%–31.1%) and 10.8% (95% CI 10.8%–10.8%) of procedures, respectively, whereas the rates of preoperative echocardiography and stress testing were 2.9% (95% CI 2.9%–2.9%) and 2.1% (95% CI 2.1%–2.1%), respectively. Significant variation was present across institutions, with the frequency of preoperative ECG ranging from 3.4% to 88.8%. Receipt of preoperative ECG and radiography were associated with older age (among patients 66–75 years of age, for ECG, adjusted odds ratio [OR] 18.3, 95% CI 17.6–19.0; for radiography, adjusted OR 2.9, 95% CI 2.8–3.0), preoperative anesthesia consultation (for ECG, adjusted OR 8.7, 95% CI 8.5–8.8; for radiography, adjusted OR 2.2, 95% CI 2.1–2.2) and preoperative medical consultation (for ECG, adjusted OR 6.8, 95% CI 6.7–6.9; for radiography, adjusted OR 3.6, 95% CI 3.5–3.6). The median ORs for receipt of preoperative ECG and radiography were 2.3 and 1.6, respectively.Interpretation:Despite guideline recommendations to limit testing before low-risk surgical procedures, preoperative ECG and chest radiography were performed frequently. Significant variation across institutions remained after adjustment for patient- and institution-level factors.

Despite the development of ultrasound‐guided techniques in regional anaesthesia, unintentional intraneural injections with neurological complications still occur. We report a case of spinal accessory nerve injury after continuous interscalene block and general anaesthesia for shoulder arthroscopy in the sitting position. Our report alerts the anaesthetist to the potential risk of this injury during ultrasound‐guided interscalene block and encourages them to avoid a high posterior puncture site.

Gabapentin is increasingly being used for the treatment of postoperative pain and a variety of psychiatric diseases, including chronic anxiety disorders. Trials have reported mixed results when gabapentin has been administered for the treatment of preoperative anxiety. We tested the hypothesis that gabapentin 1,200 mg vsplacebo would reduce preoperative anxiety in patients who exhibit moderate to high preoperative anxiety. A blinded randomized controlled trial was conducted from September 2009 to June 2011 at the Toronto General Hospital. Following ethics approval and informed consent, 50 female patients with a 0-10 numeric rating scale (NRS) anxiety score of greater than or equal to 5/10 consented to receive either gabapentin 1,200 mg (n= 25) or placebo (n= 25) prior to surgery. Randomization was computer generated, and the Investigational Pharmacy was responsible for the blinding and dispensing of medication. All patients and care providers, including physicians, nurses, and study personnel, were blinded to group allocation. Before administering the study medication, baseline anxiety levels were measured using a NRS, the Spielberger State-Trait Anxiety Inventories, the Pain Catastrophizing Scale, and the Pain Anxiety Symptoms Scale-20. Baseline pain intensity (0-10 NRS) and level of sedation (0-10 NRS and Richmond Agitation-Sedation Scale [RASS]) were also measured. Two hours after the administration of gabapentin or placebo (prior to surgery), patients again rated their anxiety, pain, and sedation levels using the same measurement tools as at baseline. The main outcome was a reduction in preoperative anxiety. Forty-four patients (22 treated with gabapentin 1,200 mg and 22 treated with placebo) were included in the analysis of the primary outcome. Analysis of covariance in which pre-drug NRS anxiety scores were used as the covariate showed that post-drug preoperative NRS anxiety (Effect size, 1.44; confidence interval [CI] 0.19 to 2.70) and pain catastrophizing (Effect size, 0.43; CI 0.12 to 0.74) scores were significantly lower in the gabapentin group than in the placebo control group, respectively. Post-drug sedation (Effect size, −3.02; CI −4.28 to −1.77) and RASS (Effect size, 0.41; CI 0.12 to 0.71) scores were significantly higher in the gabapentin group than in the placebo group, respectively. Administration of gabapentin 1,200 mg prior to surgery reduces preoperative NRS anxiety scores and pain catastrophizing scores and increases sedation prior to entering the operating room. These results suggest that gabapentin 1,200 mg may be a treatment option for patients who exhibit high levels of preoperative anxiety and pain catastrophizing; however, the sedative properties of the medication and the possibility of delayed postoperative discharge in the elective ambulatory population need to be considered. La gabapentine est de plus en plus utilisée pour le traitement de la douleur postopératoire ainsi que pour le traitement de plusieurs maladies psychiatriques, notamment les troubles anxieux chroniques. Des études ont rapporté des résultats mitigés lors de l’administration de gabapentine pour le traitement de l’anxiété préopératoire. Nous avons testé l’hypothèse que 1200 mg de gabapentine vs. un placebo réduirait l’anxiété préopératoire chez les patients manifestant une anxiété préopératoire modérée à élevée. Nous avons réalisé une étude randomisée contrôlée en aveugle entre septembre 2009 et juin 2011 à l’Hôpital général de Toronto. Après avoir obtenu l’approbation du comité d’éthique et le consentement éclairé des sujets de l’étude, 50 patientes ayant un score d’anxiété sur une échelle d’évaluation numérique (ÉÉN) de 0-10 supérieur ou égal à 5/10 ont consenti à recevoir 1200 mg de gabapentine (n= 25) ou un placebo (n= 25) avant la chirurgie. La randomisation a été effectuée par ordinateur, et le département de pharmacie était en charge de la mise en aveugle et de l’administration du médicament. Personne parmi les patientes ou les fournisseurs de soins, y compris les médecins, les infirmières et le personnel de recherche, ne connaissait l’attribution des groupes. Avant l’administration du médicament à l’étude, les niveaux d’anxiété de base ont été mesurés à l’aide d’une ÉÉN, des inventaires d’anxiété situationnelle et de trait d’anxiété de Spielberger, de l’échelle de catastrophisation de la douleur, et de l’échelle des symptômes d’anxiété face à la douleur 20. L’intensité de la douleur de base (ÉÉN 0-10) et le niveau de sédation (ÉÉN 0-10 et échelle de sédation-agitation de Richmond [RASS]) ont également été mesurés. Deux heures après l’administration de la gabapentine ou du placebo (avant la chirurgie), les patientes ont à nouveau attribué une note à leur anxiété, à leur douleur, et aux niveaux de sédation à l’aide des mêmes outils de mesure qu’au début. Le critère d’évaluation principal était une réduction de l’anxiété préopératoire. Quarante-quatre patientes (22 traitées avec 1200 mg de gabapentine et 22 traitées avec placebo) ont été incluses dans l’analyse du critère d’évaluation principal. L’analyse de la covariance, utilisant les scores d’anxiété sur l’ÉÉN avant l’administration du médicament comme covariable, a démontré que les scores d’anxiété préopératoire sur l’ÉÉN après l’administration du médicament (ampleur de l’effet, 1,44; intervalle de confiance [IC] 0,19 à 2,70) et de catastrophisation de la douleur (ampleur de l’effet, 0,43; IC 0,12 à 0,74) étaient significativement plus bas dans le groupe gabapentine que dans le groupe témoin placebo, respectivement. Les scores de sédation après administration du médicament (ampleur de l’effet, −3.02; IC −4,28 à −1,77) et de RASS (ampleur de l’effet, 0,41; IC 0,12 à 0,71) étaient significativement plus élevés dans le groupe gabapentine que dans le groupe placebo, respectivement. L’administration de 1200 mg de gabapentine avant la chirurgie réduit les scores d’anxiété préopératoire sur l’ÉÉN ainsi que les scores de catastrophisation de la douleur, et augmente la sédation avant l’entrée en salle d’opération. Ces résultats suggèrent que 1200 mg de gabapentine pourraient constituer une option de traitement pour les patients manifestant des niveaux élevés d’anxiété préopératoire et de catastrophisation de la douleur; toutefois, les propriétés sédatives du médicament et la possibilité d’un délai dans le congé postopératoire dans la population ambulatoire pour chirurgies non urgentes doivent être prises en compte.