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Introduction An individualised thromboprophylaxis was implemented in critically ill patients suffering from coronavirus disease 2019 (COVID-19) pneumonia to reduce mortality and improve clinical outcome. The aim of this study was to evaluate the effect of this intervention on clinical outcome. Methods In this mono-centric, controlled, before-after study, all consecutive adult patients with confirmed COVID-19 pneumonia admitted to ICU from March 13th to April 20th 2020 were included. A thromboprophylaxis protocol, including augmented LMWH dosing, individually tailored with anti-Xa measurements and twice-weekly ultrasonography screening for DVT, was implemented on March 31th 2020. Primary endpoint is one-month mortality. Secondary outcomes include two-week and three-week mortality, the incidence of VTE, acute kidney injury and continuous renal replacement therapy (CRRT). Multiple regression modelling was used to correct for differences between the two groups. Results 46 patients were included in the before group, 26 patients in the after group. One month mortality decreased from 39.13% to 3.85% (p, Highlights • An individualised thromboprophylaxis was implemented in critically ill COVID-19 patients. • One-month mortality was reduced after implementation of this protocol • Cumulative incidence of venous thromboembolism was lower after implementation. • Less need for continuous renal replacement therapy in the after group.

Background The aim of this paper is to describe a newly developed endoscopic coronary artery bypass graft (Endo-CABG) technique to treat patients with single- and multi-vessel disease and discuss the short-term clinical results in a large patient cohort. This technique avoids a median sternotomy by combining a thoracoscopic technique via three ∼5 mm thoracic ports and a mini-thoracotomy utility 3–4 cm port through the intercostal space. Methods From January 2016 to January 2018, data from consecutive patients undergoing an elective Endo-CABG were prospectively entered into a customized database and retrospectively reviewed. Patients scheduled for a combined hybrid intervention were excluded. Conversion rate to sternotomy, incidence of surgical revision and postoperative graft failure, one-month survival, morbidity, and length of stay (LOS) were investigated. Subgroup analyses were performed. Results A total of 342 patients undergoing an Endo-CABG with one (n = 53) or multiple (n = 289) bypasses were included. No conversion to sternotomy occurred and incidence of surgical revision, graft failure, and 30-day mortality was 7.3%, 1.5%, and 1.8%, respectively. Adverse neurological outcomes were rare: cerebrovascular accident, transient ischemic attack, epilepsy, and postoperative delirium were observed in 0.6%, 0.3%, 0.3%, and 5.3% of patients, respectively. Median intensive care unit and hospital LOS were 2.75 (IQR 1.8 to 3.8) and 8.0 days (IQR 7.0 to 10.0), respectively. Thirty-day mortality in obese patients, diabetics, and octogenarians was 0%, 3.6%, and 5.6%, respectively. EuroSCORE II > 5% was associated with a high 30-day mortality (25%). Conclusions Endo-CABG can be considered a safe and effective procedure to treat single- and multi-vessel coronary artery disease. Individual patient selection seems not necessary to apply this technique.

OBJECTIVES: To investigate healthcare system-driven variation in general characteristics, interventions, and outcomes in coronavirus disease 2019 (COVID-19) patients admitted to the ICU within one Western European region across three countries. DESIGN: Multicenter observational cohort study. SETTING: Seven ICUs in the Euregio Meuse-Rhine, one region across Belgium, The Netherlands, and Germany. PATIENTS: Consecutive COVID-19 patients supported in the ICU during the first pandemic wave. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Baseline demographic and clinical characteristics, laboratory values, and outcome data were retrieved after ethical approval and data-sharing agreements. Descriptive statistics were performed to investigate country-related practice variation. From March 2, 2020, to August 12, 2020, 551 patients were admitted. Mean age was 65.4 ± 11.2 years, and 29% were female. At admission, Acute Physiology and Chronic Health Evaluation II scores were 15.0 ± 5.5, 16.8 ± 5.5, and 15.8 ± 5.3 (p = 0.002), and Sequential Organ Failure Assessment scores were 4.4 ± 2.7, 7.4 ± 2.2, and 7.7 ± 3.2 (p < 0.001) in the Belgian, Dutch, and German parts of Euregio, respectively. The ICU mortality rate was 22%, 42%, and 44%, respectively (p < 0.001). Large differences were observed in the frequency of organ support, antimicrobial/inflammatory therapy application, and ICU capacity. Mixed-multivariable logistic regression analyses showed that differences in ICU mortality were independent of age, sex, disease severity, comorbidities, support strategies, therapies, and complications. CONCLUSIONS: COVID-19 patients admitted to ICUs within one region, the Euregio Meuse-Rhine, differed significantly in general characteristics, applied interventions, and outcomes despite presumed genetic and socioeconomic background, admission diagnosis, access to international literature, and data collection are similar. Variances in healthcare systems' organization, particularly ICU capacity and admission criteria, combined with a rapidly spreading pandemic might be important drivers for the observed differences. Heterogeneity between patient groups but also healthcare systems should be presumed to interfere with outcomes in coronavirus disease 2019. ispartof: CRITICAL CARE MEDICINE vol:50 issue:4 pages:595-606 ispartof: location:United States status: published

Background and objectivesDistal upper extremity surgery is commonly performed under regional anaesthesia, including intravenous regional anaesthesia (IVRA) and ultrasound-guided forearm nerve block. This study aimed to investigate if ultrasound-guided forearm nerve block is superior to forearm IVRA in producing a surgical block in patients undergoing carpal tunnel release.MethodsIn this observer-blinded, randomized controlled superiority trial, 100 patients undergoing carpal tunnel release were randomized to receive ultrasound-guided forearm nerve block (n = 50) or forearm IVRA (n = 50). The primary outcome was anaesthetic efficacy evaluated by classifying the blocks as complete vs incomplete. Complete anaesthesia was defined as total sensory block, incomplete anaesthesia as mild pain requiring more analgesics or need of general anaesthesia. Pain intensity on a numeric rating scale (0–10) was recorded. Surgeon satisfaction with hemostasis, surgical time, and OR stay time were recorded. Patient satisfaction with the quality of the block was assessed at POD 1.ResultsIn total, 43 (86%) of the forearm nerve blocks were evaluated as complete, compared to 33 (66%) of the forearm IVRA (p = 0.019). After the forearm nerve block, pain intensity was lower at discharge (-1.76 points lower, 95% CI (-2.92, -0.59), p = 0.0006) compared to patients treated with forearm IVRA. No differences in pain experienced at the start of the surgery, during surgery, and at POD1, nor in surgical time or total OR stay were observed between groups. Surgeon (p = 0.0016) and patient satisfaction (p = 0.0023) were slightly higher after forearm nerve block.ConclusionAn ultrasound-guided forearm nerve block is superior compared to forearm IVRA in providing a surgical block in patients undergoing carpal tunnel release.Trial registrationThis trial was registered asNCT03411551.

Funding Acknowledgements Type of funding sources: None. Background Repeated echocardiographic assessment of cardiac function is integral in management of intensive care units (ICU) patients. Machine learning (ML) can assist by integrating whole-cardiac cycle echo data derived from flow assessment and deformation imaging, and grouping patients on the basis of patterns of cardiac dysfunction and its evolution over time. Cardiac involvement has been suggested to be important in COVID-19 outcome and echo evaluation can inform on cardiac status. We use unsupervised ML to investigate and integrate longitudinal data from the COVID-HO study (NCT04371679) to determine the potential of tracking changes in cardiac function during ICU hospitalization. Methods In a single-centre, COVID-19 patients (n = 38) were prospectively followed with echocardiography as part of ICU management. The endpoint was defined as death or ICU discharge. LV myocardial deformation, as well as aortic, mitral and pulmonary artery blood-pool Doppler velocity profiles were used as input for ML. Clinical data was used to validate the ML derived phenotypes. Echo data from the initial and final echo examination were used to create an output space where participants were positioned based on cardiac function blinded to outcome status. Regression was used to estimate the echo and clinical characteristics of different regions in the space. Patient trajectories in the output space were investigated for each patient. Results Endpoint was not reached in 24% (n = 9) at the time of analysis. The cohort was 68% male, aged 65 ± 12 years, and with an ICU mortality 21% (n = 8). The median spent in ICU was 10 (IQR 7-18) days. The ML analysis demonstrated a heterogeneous output space (Fig 1A) we could define a gradual change in the shape of the pulmonary outflow velocity profile, from a normal towards pulmonary hypertension (Fig 1A, x axis). Jointly with differences in diastolic function (mitral inflow fusion and A wave accentuation) defined two regions: with signs of pulmonary hypertension (gray); and with normal pulmonary pressures but LV diastolic dysfunction (yellow). Investigation of patient trajectories (Fig 1B) demonstrated the feasibility of tracking changes during ICU hospitalization, showing a shift of a patient that died in the ICU, from initial diastolic dysfunction towards pulmonary hypertension (red), and a patient shifting from a region with normal diastolic function towards pulmonary hypertension, but with a positive outcome (blue). Echo data concurs with observed dynamics (Fig 1C and 1D). Conclusion ML can integrate complex, whole-cardiac cycle echo data to group heterogeneous patients based on similarity of cardiac function. Patient trajectories across the output space demonstrate the feasibility of ML for echo data-based follow-up of patients during ICU hospitalization. Further echo and clinical data integration can improve characterisation of the output space regions and better define changes in cardiac function during hospitalization. Abstract Figure 1

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 European Commission Project H2020-MSCA-ITN-2016 Background Although the cardiac burden of COVID-19 has been demonstrated, follow-up imaging studies are scarce. The aim was to use speckle-tracking deformation imaging (STE) to prospectively assess cardiac function during intensive care unit (ICU) hospitalisation, comparing ventricular and atrial function of COVID-10 patients that died and those that were discharged. Methods In a single-centre, COVID-19 patients (n = 41) (71% male, aged 65 ± 11 years) were prospectively followed with echocardiography as part of ICU treatment. The left and right ventricles (LV, RV, respectively) were studied with STE in the 4-chamber cardiac view. The endpoint was defined as death or ICU discharge. Average values of the strain parameters from the first and final scans in the ICU, respectively, were calculated for the two outcome groups. Results Endpoint was not reached in 15% (n = 6) at the time of analysis. The remaining patients (n = 32) were 69% male, aged 66 (interquartile range (IQR) 60-72) years, and with an ICU mortality 26% (n = 9). The median spent in ICU was 24 (IQR 15-43) days. On average, echocardiography was performed three times during ICU hospitalisation, amounting to 103 examinations. The changes in cardiac strain are shown in Table 1. The change in LV longitudinal strain during ICU hospitalisation is shown in Figure 1. Conclusion Worsening of LV strain and lack of improvement of RV strain is linked to higher mortality in the ICU. The assessment of cardiac function might contain prognostic information in COVID-19 patients that are admitted to the ICU. Patients discharged from thee OCU (n = 23) Patients that died in the ICU (n = 9) P value Initial echo in the ICU LV strain, % (IQR) 18.00 (15.6-19.95) 14.4 (10.56-20.42) 0.158 RV strain, % (IQR) 16.00 (14.70-20.05) 15.50 (10.38-23.70) 0.712 Final echo before discharge LV strain, % (IQR) 17.35 (15.13-18.98) 13.20 (10.75-15.40) 0.007 RV strain, % (IQR) 17.65 (16.83-19.60) 15.75 (10.68-20.43) 0.438 ICU - intensive care unit; IQR-inter-quartile range Abstract Figure 1

Background/Objectives This study aimed to study one-month recovery profile and to identify predictors of Quality of Recovery (QOR) after painful day surgery and investigate the influence of pain therapy on QOR. Methods/Design This is a secondary analysis of a single-centre, randomised controlled trial of 200 patients undergoing ambulatory haemorrhoid surgery, arthroscopic shoulder or knee surgery, or inguinal hernia repair between January 2016 and March 2017. Primary endpoints were one-month recovery profile and prevalence of poor/good QOR measured by the Functional Recovery Index (FRI), the Global Surgical Recovery index and the EuroQol questionnaire at postoperative day (POD) 1 to 4, 7, 14 and 28. Multiple logistic regression analysis was performed to determine predictors of QOR at POD 7, 14, and 28. Differences in QOR between pain treatment groups were analysed using the Mann-Whitney U test. Results Four weeks after haemorrhoid surgery, inguinal hernia repair, arthroscopic knee and arthroscopic shoulder surgery, good QOR was present in 71%, 76%, 57% and 24% respectively. Poor QOR was present in 5%, 0%, 7% and 29%, respectively. At POD 7 and POD 28, predictors for poor/intermediate QOR were type of surgery and a high postoperative pain level at POD 4. Male gender was another predictor at POD 7. Female gender and having a paid job were also predictors at POD 28. Type of surgery and long term fear of surgery were predictors at POD 14. No significant differences in total FRI scores were found between the two different pain treatment groups. Conclusions The present study shows a procedure-specific variation in recovery profile in the 4-week period after painful day surgery. The best predictors for short-term (POD 7) and long-term (POD 28) poor/intermediate QOR were a high postoperative pain level at POD 4 and type of surgery. Different pain treatment regimens did not result in differences in recovery profile. Trial registration European Union Clinical Trials Register 2015-003987-35.

Background Belgium was among the first countries in Europe with confirmed coronavirus disease 2019 (COVID-19) cases. Since the first diagnosis on February 3rd, the epidemic has quickly evolved, with Belgium at the crossroads of Europe, being one of the hardest hit countries. Although risk factors for severe disease in COVID-19 patients have been described in Chinese and United States (US) cohorts, good quality studies reporting on clinical characteristics, risk factors and outcome of European COVID-19 patients are still scarce. Methods This study describes the clinical characteristics, complications and outcomes of 319 hospitalized COVID-19 patients, admitted to a tertiary care center at the start of the pandemic in Belgium, and aims to identify the main risk factors for in-hospital mortality in a European context using univariate and multivariate logistic regression analysis. Results Most patients were male (60%), the median age was 74 (IQR 61–83) and 20% of patients were admitted to the intensive care unit, of whom 63% needed invasive mechanical ventilation. The overall case fatality rate was 25%. The best predictors of in-hospital mortality in multivariate analysis were older age, and renal insufficiency, higher lactate dehydrogenase and thrombocytopenia. Patients admitted early in the epidemic had a higher mortality compared to patients admitted later in the epidemic. In univariate analysis, patients with obesity did have an overall increased risk of death, while overweight on the other hand showed a trend towards lower mortality. Conclusions Most patients hospitalized with COVID-19 during the first weeks of the epidemic in Belgium were admitted with severe disease and the overall case fatality rate was high. The identified risk factors for mortality are not easily amenable at short term, underscoring the lasting need of effective therapeutic and preventative measures.

Corona virus disease 2019 (COVID-19) has been associated with a wide range of divergent pathologies, and risk of severe disease is reported to be increased by a similarly broad range of co-morbidities. The present study investigated blood metabolites in order to elucidate how infection with severe acute respiratory syndrome coronavirus 2 can lead to such a variety of pathologies and what common ground they share. COVID-19 patient blood samples were taken at hospital admission in two Belgian patient cohorts, and a third cohort that included longitudinal samples was used for additional validation (total n=581). A total of 251 blood metabolite measures and ratios were assessed using nuclear magnetic resonance spectroscopy and tested for association to disease severity. In line with the varied effects of severe COVID-19, the range of severity-associated biomarkers was equally broad and included increased inflammatory markers (glycoprotein acetylation), amino acid concentrations (increased leucine and phenylalanine), increased lipoprotein particle concentrations (except those of very low density lipoprotein, VLDL), decreased cholesterol levels (except in large HDL and VLDL), increased triglyceride levels (only in IDL and LDL), fatty acid levels (decreased poly-unsaturated fatty acid, increased mono-unsaturated fatty acid) and decreased choline concentration, with association sizes comparable to those of routine clinical chemistry metrics of acute inflammation. Our results point to systemic metabolic biomarkers for COVID-19 severity that make strong targets for further fundamental research into its pathology (e.g. phenylalanine and omega-6 fatty acids).

BACKGROUND: Nowadays, complicated and painful surgical procedures are encouraged to be carried out in an ambulatory setting. OBJECTIVES: The current study aimed to assess 4-week postoperative pain profiles of 4 painful ambulatory surgical procedures. We analyzed the prevalence of and reasons for non-adherence and partial adherence of patients to a predefined treatment schedule after the ambulant surgery. METHODS: The current study analyzed data from a large randomized trial by evaluating the effect of postoperative pain medication on acute postoperative pain at home during the first 4 postoperative days (POD) in patients scheduled for ambulatory hemorrhoid surgery, shoulder or knee arthroscopy, and inguinal hernia repair. Postoperative pain intensity was assessed at POD 0, 1, 2, 3, 4, 7, 14, and 28 via the Numeric Rating Scale (NRS). Adherence was assessed on POD 1, 2, 3, and 4. RESULTS: Median average pain scores were above an NRS of 3 during the first postoperative week after shoulder arthroscopy and even above 4 during the first postoperative week after hemorrhoid surgery. 26% of patients undergoing shoulder arthroscopy and hemorrhoid surgery still had moderate pain 1 week after surgery. Median average pain scores were below an NRS of 3 during the whole study period after inguinal hernia repair and knee arthroscopy. 24.61% of patients did not use the study medication as prescribed, 5.76% of whom were non-adherent, and 18.85% were partially adherent. CONCLUSIONS: Each type of ambulant surgery has its unique postoperative pain profile. New strategies should be developed for pain therapy at home, particularly after the ambulatory arthroscopic shoulder surgery and hemorrhoid surgery. Non-adherence is uncommon if they are provided with a multimodal analgesic home kit together with clear verbal, written instructions, and intensive follow-up. ispartof: Anesth Pain Med vol:10 issue:3 pages:e101669- ispartof: location:Netherlands status: Published online

Contains fulltext : 229328.pdf (Publisher’s version ) (Open Access) BACKGROUND: Many studies investigate the role of pharmacological treatments on disease course in Corona Virus Disease 2019 (COVID-19). Sex disparities in genetics, immunological responses, and hormonal mechanisms may underlie the substantially higher fatality rates reported in male COVID-19 patients. To optimise care for COVID-19 patients, prophylactic and therapeutic studies should include sex-specific design and analyses. Therefore, in this scoping review, we investigated whether studies on pharmacological treatment in COVID-19 were performed based on a priori sex-specific design or post-hoc sex-specific analyses. METHODS: We systematically searched PubMed, EMBASE, UpToDate, clinical trial.org, and MedRxiv for studies on pharmacological treatment for COVID-19 until June 6th, 2020. We included case series, randomized controlled trials, and observational studies in humans (≥18 years) investigating antiviral, antimalarial, and immune system modulating drugs. Data were collected on 1) the proportion of included females, 2) whether sex stratification was performed (a priori by design or post-hoc), and 3) whether effect modification by sex was investigated. FINDINGS: 30 studies were eligible for inclusion, investigating remdesivir (n = 2), lopinavir/ritonavir (n = 5), favipiravir (n = 1), umifenovir (n = 1), hydroxychloroquine/chloroquine (n = 8), convalescent plasma (n = 6), interleukin-6 (IL-6) pathway inhibitors (n = 5), interleukin-1 (IL-1) pathway inhibitors (n = 1) and corticosteroids (n = 3). Only one study stratified its data based on sex in a post-hoc analysis, whereas none did a priori by design. None of the studies investigated effect modification by sex. A quarter of the studies included twice as many males as females. INTERPRETATION: Analyses assessing potential interference of sex with (side-)effects of pharmacological therapy for COVID-19 are rarely reported. Considering sex differences in case-fatality rates and genetic, immunological, and hormonal mechanisms, studies should include sex-specific analyses in their design to optimise COVID-19 care. FUNDING: None.

An amendment to this paper has been published and can be accessed via the original article. van Halem, K (corresponding author), Jessa Hosp, Dept Infect Dis & Immun, Stadsomvaart 11, B-3500 Hasselt, Belgium. karlijn.vanhalem@jessazh.be

OBJECTIVES: In 2009, Gramke et al have described predictive factors to pre-operatively detect those at risk for moderate to severe acute postoperative pain (APSP) after day surgery. The aim of the present study is to externally validate this initial model and to improve and internally validate a modified version of this model.METHODS: Elective patients scheduled for day surgery were prospectively enrolled from November 2008 to April 2010. Model discrimination was quantified using the area under the receiver operating characteristic curve (AUC). Model calibration was assessed by visual inspection of the calibration plot. Subsequently, we modified (different assignment of type of surgery, different cut-off for moderate to severe APSP, continuous of dichotomized variables and testing of additional variables) and internally validated this model by standard bootstrapping techniques.RESULTS: A total of 1118 patients were included. The AUC for the original model was 0.81 in the derivation dataset and 0.72 in our validation dataset. The model showed poorly calibrated risk predictions. The AUC of the modified model was 0.82 (optimism-corrected AUC=0.78). This modified model showed good calibration.CONCLUSION: The original prediction model of Gramke et al performed insufficient on our cohort of outpatients with respect to discrimination and calibration. Internal validation of a modified model shows promising results. In this model, preoperative pain, patient derived expected pain and different types of surgery are the strongest predictors of moderate to severe APSP after day surgery.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/4.0.

Background: COVID-19 patients are related with an elevated risk for deep venous thrombosis (DVT). We evaluated the prevalence of DVT in our intubated and mechanically ventilated COVID-19+ patients at March 29th. Methods: We performed a Mono-center, investigator-initiated, observational, cross-sectional study. A total of 12 intubated COVID-19+ patients at intensive care unit (ICU) ward C3 of the Jessa Hospital, Hasselt, Belgium at March 29th were included. All patients received a prophylactic dose of low-molecular-weight heparin (LMWH). All intubated and mechanically ventilated patients were screened for the presence of DVT in femoral, popliteal, jugular and inferior caval veins with duplex ultrasound. Results: In total, 8 from all 12 intubated and ventilated COVID 19+ patients had already developed minimally one DVT. No relevant correlations could be detected. Conclusions: The prevalence of DVT in critically ill ICU patients with COVID-19 is over 60% despite adequate treatment with a prophylactic dose of LMWH. We suggest the use of graduated compression (elastic) stockings (GCS) and intermediate-dose LMWH for thrombosis prophylaxis in all COVID-19 patients. Since there were no clinical signs of DVT, we suggest to routinely screen all COVID-19 patients admitted to ICU for DVT via ultrasound. Future research should focus on the mechanisms underlying these observations.

Introduction To ensure patient safety during Totally Endoscopic Cardiac Surgeries (TECS), patients are peripherally cannulated for coupling to the Cardiopulmonary Bypass (CPB) (1). Despite its necessity, the cannulated leg might experience clinically relevant ischemia (CRI), defined as a minimum of 15% Tissue Oxygenation Index (TOI) drop, lasting at least 4 minutes, possibly leading to poor peri- and postoperative clinical outcomes (2). TOI-values were assessed using non-invasive, Near-Infrared Spectroscopy (NIRS; 200NX-NIRO, Hamamatsu®, Japan) measurements of the skin covering the ipsilateral calf muscles. NIRS enables the quantification of the TOI, based on the difference in light absorption between oxygenated en deoxygenated haemoglobin molecules. The 200NX-NIRO has shown great sensitivity and specificity in the clinical setting (3-5). The objective was to evaluate the prevalence of poor distal leg perfusion related to short-term, peri-operative, CPB-time, since these data remain largerly unknown. Methods All consecutive patients 18 years or older, and scheduled for a TECS-based valve surgery (YIL AVR and/or MVATS), coronary surgery (ENDO ACAB or ENDO CABG), or a combination were included. Perioperative TOI-values were assessed at: baseline (B) = 5 minutes before insertion of the femoral arterial cannula (FAC); Event 1 (E1) = insertion of the FAC; Event 2 (E2) = onset of CPB; Event 3 (E3) = offset of CPB; Event 4 (E4) = removal of the FAC. Results 116 patients were included for statistical analysis. Differences between TOI-values were analysed using Wilcoxon signed rank tests. CRI in the cannulated leg was demonstrated in 18,80% (n = 22) of all cases, and showed significantly lower TOI-values for all events (E1, E2, E3 and E4) compared to the baseline TOI-value (Figure 1): p Discussion Although not all patients showed CRI in the cannulated leg, some degree of hypoperfusion was demonstrated over all cannulated legs. However, these are interim results and thus, further research regarding postoperative follow-up is necessary and might offer insights on how to prevent or prematurely treat ischemia and/or ischemia-related complications in the subclinical stage.

BACKGROUND: The main objective of this review is to perform a systematic review and meta-analysis of the existing evidence related to the analgesic efficacy with the use of conventional, upper arm intravenous regional anesthesia (IVRA) as compared to a modified, forearm IVRA in adult patients undergoing procedures on the distal upper extremity. METHODS: MEDLINE, EMBASE and CENTRAL (Cochrane) databases were searched for randomized controlled trials published in English, French, Dutch, German or Spanish language. Primary outcomes of interest including description of quality level of anesthesia and onset of sensory block were assessed for this review. Dosage of the local anesthetic, local anesthetic toxicity and need for sedation due to tourniquet pain were considered as secondary outcomes. RESULTS: Our literature search yielded 3 papers for qualitative synthesis. Four other articles were added into a parallel analysis of 7 reports that provided data on the incidence of complications and success rate after forearm IVRA. Forearm IVRA was found to be as efficient as upper arm IVRA (RR = 0.98 [0.93, 1.05], P = 0.78), but comes with the advantage of a lower need for sedation due to less tourniquet pain. CONCLUSION: Our results demonstrate that forearm IVRA is as effective in providing a surgical block as compared to a conventional upper arm IVRA, even with a reduced, non-toxic dosage of local anesthetic. No severe complications were associated with the use of a forearm IVRA. Other benefits of the modified technique include a faster onset of sensory block, better tourniquet tolerance and a dryer surgical field. REGISTRATION OF THE SYSTEMATIC REVIEW: A review protocol was published in the PROSPERO register in November 2015 with registration number CRD42015029536 . ispartof: BMC Anesthesiology vol:18 issue:1 ispartof: location:England status: published

BACKGROUND AND OBJECTIVES: This randomized trial aimed to assess if a combined suprascapular-axillary nerve block (SSB) is noninferior (margin = 1.3 on a 0- to 10-point scale) to interscalene block (ISB) in treating pain after arthroscopic shoulder surgery. Secondary end points included opioid consumption, dyspnea, discomfort associated with muscle weakness, and patient satisfaction. METHODS: One hundred patients undergoing arthroscopic shoulder surgery were randomized to receive ultrasound-guided ISB (n = 50) or SSB (n = 50). Pain intensity at rest, dyspnea, and discomfort were recorded upon arrival in the recovery room, discharge to the ward, and at 4, 8, and 24 hours after surgery. Piritramide consumption was recorded for the first 24 hours. Patient satisfaction was assessed on the second postoperative day. RESULTS: During the first 4 hours after surgery, the difference in mean pain score between SSB and ISB was higher than 2.5 (±0.8). The difference gradually decreased to 1.1 (±1.0) at 8 hours before resulting in noninferiority during the night and at 24 hours. Piritramide consumption was significantly higher in the SSB group in the first 8 hours. The incidence of dyspnea and discomfort was higher after ISB. Treatment satisfaction was similar in both groups. CONCLUSIONS: Suprascapular-axillary nerve block is inferior to ISB in terms of analgesia and opioid requirement in the immediate period after arthroscopic shoulder surgery but is associated with a lower incidence of dyspnea and discomfort. The difference in pain and opioid consumption gradually decreases as the blocks wear off in order to reach similar pain scores during the first postoperative night and at 24 hours. CLINICAL TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov, identifier NCT02415088. ispartof: REGIONAL ANESTHESIA AND PAIN MEDICINE vol:43 issue:7 pages:738-744 ispartof: location:England status: published

[Stinkens, Rudi; Verbeke, Nikolaas; Ory, Jean-Paul; Dubois, Jasperina; Stessel, Bjorn] Jessa Hosp, Dept Anaesthesiol & Pain Med, Hasselt, Belgium. [Van de Velde, Marc] Univ Leuven, KU Leuven, Dept Cardiovasc Sci, Leuven, Belgium. [Van de Velde, Marc] Univ Hosp Leuven, Dept Anaesthesiol, Leuven, Belgium. [Baldussu, Esmee; Ruiters, Chabelie; Stessel, Bjorn] Hasselt Univ, Fac Med & Life Sci, Hasselt, Belgium.

Background: Strong opioids in the home setting after ambulatory surgery have rarely been studied for fear of hazardous adverse effects such as respiratory depression. Objectives: We compared the efficacy of paracetamol/controlled-release (CR) oxycodone and paracetamol/naproxen for treatment of acute postoperative pain at home after ambulatory surgery. Secondary outcomes were adverse effects of study medication, treatment satisfaction, and postoperative analgesic compliance. Methods: Patients undergoing ambulatory knee arthroscopy or inguinal hernia repair surgery (n = 105) were randomized into 3 groups: Group1 paracetamol/naproxen (n = 35), Group 2 paracetamol/CR oxycodone for 24 hours (n = 35), and Group 3 paracetamol/CR oxycodone for 48 hours (n = 35). Pain intensity at movement and at rest using a visual analog scale as well as satisfaction with postoperative analgesia and side effects were recorded for up to 48 hours postoperatively. Compliance with study medication was also assessed. Results: For pain at movement and at rest, no significant differences were found between the paracetamol/naproxen group and either the paracetamol/CR oxycodone for 24 hours group (β = 2.6 [4.9]; P = 0.597) or the paracetamol/CR oxycodone for 48 hours (β = –1.7 [5.1]; P = 0.736). No major adverse effects of study medication were registered and satisfaction with postoperative pain treatment was high in all groups. Compliance was comparable across the groups. Despite clear instructions, 8 patients with the lowest pain scores did not use any of the prescribed pain medication. Conclusions: Paracetamol/CR oxycodone and paracetamol/naproxen are equally effective in treatment of acute postoperative pain at home after ambulatory surgery with comparable patient satisfaction level. We suggest paracetamol/CR oxycodone to be a valuable alternative for the current paracetamol/naproxen gold standard, particularly in patients with a contraindication for nonsteroidal anti-inflammatory drugs. ClinicalTrials.gov identifier: NCT02152592.

ispartof: INTERNATIONAL JOURNAL OF OBSTETRIC ANESTHESIA vol:34 pages:113-114 ispartof: location:Netherlands status: published

Nijs, K (reprint author), Jessa Hosp, Dept Anesthesiol & Pain Med, Hasselt, Belgium. Jessa Hosp, Dept Anesthesiol & Pain Med, Hasselt, Belgium.

Traditionally, major complications and unanticipated admission/readmission rates were used to assess outcome after day surgery. However, in view of the relative absence of major complications the quality of recovery (QOR) should be considered one of the principal endpoints after day surgery. In our study, the level of QOR is defined by a combination of the Global Surgical Recovery (GSR) Index and the Quality of Life (QOL). The aim of this study was to analyze prevalence and predictors of QOR after day surgery on the fourth postoperative day. Elective patients scheduled for day surgery from November 2008 to April 2010 were enrolled in a prospective cohort study. Outcome parameters were measured by using questionnaire packages at 2 time points: 1 week preoperatively and 4 days postoperatively. Primary outcome parameter is the QOR and is defined as good if the GSR index >80% as well as the postoperative QOL is unchanged or improved as compared with baseline. QOR is defined as poor if both the GSR index ≤ 80% and if the postoperative QOL is decreased as compared with baseline. QOR is defined as intermediate in all other cases. Three logistic regression analyses were performed to determine predictors for poor QOR after day surgery. A total of 1118 patients were included. A good QOR was noted in 17.3% of patients, an intermediate QOR in 34.8%, and a poor QOR in 47.8% 4 days after day surgery. The best predictor for poor QOR after day surgery was type of surgery. Other predictors were younger age, work status, and longer duration of surgery. A history of previous surgery, expected pain (by the patient) and high long-term surgical fear were significant predictors of poor QOR in only 1 of 3 prediction models. The QOR at home 4 days after day surgery was poor in the majority of patients and showed a significant procedure-specific variation. Patients at risk for poor QOR can be identified during the preoperative period based on type of surgery, age, work status, and the duration of the surgery.

Objectives: To prospectively describe the prevalence and predictive factors of chronic postsurgical pain (CPSP) and poor global recovery in a large outpatient population at a university hospital, 1 year after outpatient surgery. Materials and Methods: A prospective longitudinal cohort study was performed. During 18 months, patients presenting for preoperative assessment were invited to participate. Outcome parameters were measured by using questionnaires at 3 timepoints: 1 week preoperatively, 4 days postoperatively, and 1 year postoperatively. A value of >3 on an 11-point numeric rating scale was considered to indicate moderate to severe pain. A score of 80% on the Global Surgical Recovery Index was defined as poor global recovery. Results: A total of 908 patients were included. The prevalence of moderate to severe preoperative pain was 37.7%, acute postsurgical pain 26.7%, and CPSP 15.3%. Risk factors for the development of CPSP were surgical specialty, preoperative pain, preoperative analgesic use, acute postoperative pain, surgical fear, lack of optimism, and poor preoperative quality of life. The prevalence of poor global recovery was 22.3%. Risk factors for poor global recovery were recurrent surgery because of the same pathology, preoperative pain, preoperative analgesic use, surgical fear, lack of optimism, poor preoperative and acute postoperative quality of life, and follow-up surgery during the first postoperative year. Discussion: Moderate to severe CPSP after outpatient surgery is common, and should not be underestimated. Patients at risk for developing CPSP can be identified during the preoperative phase.

Objective To determine postoperative pain in different types of ear, nose, and throat (ENT) surgery and their psychological preoperative predictors. Design Prospective cohort study. Setting Academic hospital. Patients A total of 217 patients undergoing ENT surgery. Interventions All ENT, neck, and salivary gland surgery. Main Outcome Measures Postoperative pain and predictors for postoperative pain. Results Fifty percent of the patients undergoing surgery on the oral, pharyngeal, and laryngeal region and on the neck and salivary gland region had a visual analog scale score higher than 40 mm on day 1. In the patients who underwent oropharyngeal region operations the VAS score remained high on all 4 days. A VAS pain score higher than 40 mm was found in less than 30% of patients after endoscopic procedures and less than 20% after ear and nose surgery. After bivariate analysis, 6 variables–age, sex, preoperative pain, expected pain, short-term fear, and pain catastrophizing–had a predictive value. Multivariate analysis showed only preoperative pain, pain catastrophizing, and anatomical site of operation as independent predictors. Conclusions Differences exist in the prevalence of unacceptable postoperative pain between ENT operations performed on different anatomical sites. A limited set of variables can be used to predict the occurrence of unacceptable postoperative pain after ENT surgery.

Background Postoperative pain and, in a more extended perspective, quality of recovery (QOR) should be considered the principal endpoints after day surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) and paracetamol are a cornerstone of pain treatment after painful day surgery. Nevertheless, NSAIDs are not always sufficiently effective, have numerous contraindications, and consequently are not suitable in up to 25 % of all patients. Metamizole is a non-opioid compound with a favourable gastrointestinal, cardiovascular and cerebrovascular profile compared to NSAIDs. The aim of this study is to assess if a combination of metamizole and paracetamol is non-inferior to a combination of ibuprofen and paracetamol in the treatment of acute postoperative pain at home after painful day case surgery. In addition, we aim to assess and compare quality of recovery (QOR) profiles of both groups. Methods/Design This is an investigator-initiated, double-blind, randomised controlled, non-inferiority trial. A total of 200 patients undergoing elective haemorrhoid surgery, arthroscopic shoulder or knee surgery, or inguinal hernia repair in a day care setting will be randomised to receive either a combination of metamizole and paracetamol (MP) or a combination of ibuprofen and paracetamol (IP). Participants will take study medication orally for 4 days. Primary endpoints are average postoperative pain intensity measured by an 11-point Numeric Rating Scale at postoperative day 1 and QOR profile measured by the Functional Recovery Index (FRI), the 1-item Global Surgical Recovery (GSR) index and the EuroQol (EQ-5D) questionnaire at days 1, 2, 3, 4, 7, 14 and 28 postoperatively. Secondary outcomes include compliance with study medication, adverse effects of study medication, use of rescue medication and satisfaction with study medication, surgery and hospital care and telephone follow-up. Discussion This study will provide clinical evidence on the analgesic efficacy and safety of a combination of metamizole and paracetamol in treating postoperative pain at home after painful day surgery. This study may also provide an insight into QOR profile after four different types of surgery and into the interrelationship between three different instruments used to assess QOR. Trial status Recruitment is currently ongoing. Trial registration European Union Clinical Trials Register 2015-003987-35. Registered 10 November 2015.