Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort

Effect of low-concentration carbohydrate on patient-centered quality of recovery in patients undergoing thyroidectomy: a prospective randomized trial

BACKROUND

At present, low-concentration carbohydrate is rarely used in minor trauma surgery, and its clinical efficacy is unknown. The aim of the study was to evaluate the effect of preoperative oral low-concentration carbohydrate on patient-centered quality of recovery in patients undergoing thyroidectomy using Quality of Recovery - 15 (QoR-15) questionnaire.

METHODS

One hundred twenty patients were randomized to oral intake of 300 ml carbohydrate solution (CH group) or 300 ml pure water (PW group) 2 h before surgery or fasting for 8 h before surgery (F group). The QoR-15 questionnaire was administered to compare the quality of recovery at 1d before surgery (T0), 24 h, 48 h, 72 h after surgery (T1, T2, T3), and perioperative blood glucose was recorded.

RESULTS

Compared to the F group, the QoR-15 scores were statistically higher in the CH and PW group at T1 (P < 0.05), and the enhancement of recovery quality reached the clinical significance at T1 in the CH group compared with the F group. Among the five dimensions of the QoR-15 questionnaire, physical comfort, physiological support and emotional dimension in the CH group were significantly better than the F group (P < 0.05) at T1. Besides, blood glucose of CH group was significantly lower than the PW group and F group at each time point after surgery.

CONCLUSIONS

Low-concentration carbohydrate could decrease the incidence of postoperative hyperglycemia and improve the patient-centered quality of recovery on patients undergoing open thyroidectomy at the early stage postoperatively.

TRIAL REGISTRATION

ChiCTR1900024731 . Date of registration: 25/07/2019.

Mode of Anesthesia and Quality of Recovery After Breast Surgery: A Case Series of 100 Patients

PURPOSE

Regional anesthesia techniques may improve patient recovery beyond treating postoperative pain alone and may facilitate patients in their return to functional, psychological as well as emotional baselines. We hypothesized that the quality of recovery (QoR) experienced by patients following breast surgery was associated with the type of anesthesia received as well as the use of a regional anesthesia technique during surgery.

METHODS

We performed a single-center prospective, observational cohort study of patients undergoing elective breast procedures (both cancer and non-cancer surgery).

RESULTS

 One hundred patients completed baseline QoR-15 questionnaires prior to surgery, of which 96 also completed QoR-15 questionnaires on postoperative day 1. The median (IQR) QoR-15 score at baseline was 133 (124-141), decreasing to 121 (106.75-136.25) on postoperative day 1. In multivariable linear regression analysis, paravertebral blocks (PVB) were associated with a 16.7 point higher overall QoR-15 score on postoperative day 1 compared to no block (95% Confidence Interval [CI]: 7.7-25.8, p<0.001); while the use of combination blocks was associated with a 21.8 point higher postoperative QoR-15 score compared to no block (95% CI: 12.8-30.8, p<0.001). PVB and combination blocks were further associated with better postoperative pain, physical comfort, physical independence and emotional state scores, compared with no block. The use of total intravenous anesthetic was not associated with differences in postoperative QoR-15 score versus volatile anesthetic, after covariate adjustment.

CONCLUSION

Breast surgery patients receiving PVB or a combination of regional blocks during surgery have higher postoperative QoR-15 scores, after adjustment for other factors.

Incidence and Risk Factors of Postoperative Severe Discomfort After Elective Surgery Under General Anesthesia: A Prospective Observational Study

PURPOSE

Patient comfort is an important concern in patients receiving surgery, but the seriousness of discomfort during recovery is unknown. We investigated the incidence of postoperative discomfort based on the Standardized Endpoints in Perioperative Medicine initiative for patient comfort, and identified the risk factors.

DESIGN

This was a single-center prospective observational study.

METHODS

We enrolled adult patients who underwent elective surgery under general anesthesia between July and December 2018 at West China Hospital of Sichuan University (ChiCTR1800017324). The primary outcome was the incidence of postoperative severe discomfort (PoSD), defined as occurring when a patient experienced a severe rating in two or more domains in the six domains in the Standardized Endpoints in Perioperative Medicine initiative on the same day, including rest pain, postoperative nausea, and vomiting, dissatisfaction of gastrointestinal recovery, dissatisfaction of mobilization, sleep disturbance, and recovery. A generalized estimated equation was constructed to find risk factors of PoSD.

FINDINGS

In total, 440 patients completed the study. The incidence of PoSD was 28% on postoperative day (POD) 1, 13% on POD 2, 9% on POD 3, and 3.6% on both POD 5 and 7. The most common discomfort was serious sleep disturbance, ranging from 43% to 10% in the first week after surgery. Longer operative time (odds ratio [95% confidence interval]: 1.56 [1.19 to 2.05], P = .001), gastrointestinal surgery (5.03[2.08,12.17], P < .001), orthopaedic surgery (3.03 [1.35,6.79], P = .007), ear, nose, and throat (ENT) surgery (3.50 [1.22,10.02], P = .020) and postoperative complications (1.77 [1.03-3.04], P = .038) were significant risk factors of PoSD.

CONCLUSIONS

The incidence of PoSD after elective surgery under general anesthesia is high. Sleep disturbance was the most common problem identified. Anesthesia providers and perianesthesia nurses may need to optimize anesthetic application, combine different anesthesia methods, improve perioperative management, and provide interventions to reduce and to treat discomfort after surgeries.

Efficacy of the erector spinae plane (ESP) block for quality of recovery in posterior thoraco-lumbar spinal decompression surgery: study protocol for a randomised controlled trial

Background

Spinal surgery can be associated with significant postoperative pain. Erector spinae plane (ESP) block is a new regional anaesthesia technique, which promises effective postoperative analgesia compared with systemically administered opioids, but has never been evaluated in terms of patient-centred outcomes such as quality of recovery and overall morbidity after major thoraco-lumbar spinal surgery.

Methods

We are conducting a prospective, randomised, double-blind trial in two hospitals in the Republic of Ireland. The sample size will be 50 patients (25 in the intervention group and 25 in the control group). Randomisation will be done using computer-generated concealed envelopes. Both patients and investigators collecting outcome data will be masked to group allocation. Participants will be male or female, aged 18 years and over, capable of providing informed consent and ASA grade I–IV. Patients scheduled to undergo posterior approach thoraco-lumbar decompression surgery involving 2 or more levels will be recruited to the study. Participants randomised to the intervention arm of the study will receive bilateral ultrasound-guided ESP block totalling 40 ml 0.25% levo-bupivcaine (20 ml each side), post induction of general anaesthesia and before surgical incision. The control group will not receive an ESP block. Both groups will receive the same standardised analgesic protocol both intra- and postoperatively. The primary outcome will be the quality of recovery at 24 h postoperatively as determined by the QoR-15 score. This score is determined by a questionnaire which measures patient responses to 15 subjective parameters, each response graded on a scale from 0 to 10. The maximum score achievable is 150 with a potential minimum score of 0. Higher scores indicate a higher quality of recovery experience.

Secondary outcomes will include area under the curve (AUC) of VRS pain versus time at rest and on movement up to 24 h postoperatively, 24 h opioid consumption, time to first analgesia in recovery, length of stay (LOS), incidence and severity of postoperative complications as measured by the Comprehensive Complication Index (CCI) score.

Discussion

To the best of our knowledge, this will be the first randomised control trial to examine the efficacy and safety of the ESP block in terms of patient-centred outcomes in the setting of major spinal surgery. The QoR-15 is a validated means of assessing the quality of recovery after surgery and gives a more holistic assessment of the recovery experience from the patient’s point of view.

Trial registration

This trial is pre-registered on ClinicalTrials.gov reference number NCT04370951. Registered on 30 April 2020. All items from the World Health Organisation Trial Registration Data Set have been included.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05101-2.

Methodologies for systematic reviews with meta-analysis of randomised clinical trials in pain, anaesthesia, and perioperative medicine

Systematic reviews and meta-analyses (SRMAs) are increasing in popularity, but should they be used to inform clinical decision-making in anaesthesia? We present evidence that the certainty of evidence from SRMAs in anaesthesia (and in general) may be unacceptably low because of risks of bias exaggerating treatment effects, unexplained heterogeneity reducing certainty in estimates, random errors, and widespread prevalence of publication bias. We also present the latest methodological advances to help improve the certainty of evidence from SRMAs. The target audience includes both review authors and practising clinicians to help with SRMA appraisal. Issues discussed include minimising risks of bias from included trials, trial sequential analysis to reduce random error, updated methods for presenting effect estimates, and novel publication bias tests for commonly used outcome measures. These methods can help to reduce spurious conclusions on clinical significance, explain statistical heterogeneity, and reduce false positives when evaluating small-study effects. By reducing concerns in these domains of Grading of Recommendations, Assessment, Development and Evaluation, it should help improve the certainty of evidence from SRMAs used for decision-making in anaesthesia, pain, and perioperative medicine.

Defining success in regional anaesthesia

Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.

Randomized controlled trial comparing the efficacy of pectoral nerve block with general anesthesia alone in patients undergoing unilateral mastectomy

This study was conducted to evaluate the efficacy of pectoral nerve block for post-operative analgesia in breast surgery patients. This double blinded, randomized controlled trial was conducted after Clinical Trials Registry-India registration. Sixty ASA grade I-II female patients undergoing unilateral modified radical mastectomy under general anesthesia, were recruited pre-operatively in two groups. PECS group (n  =  29) was given ipsilateral pectoral nerve block I & II while the CONTROL group (n  =  29) directly proceeded to surgery. Our primary outcome was comparison of immediate post-operative pain scores at rest and movement. The secondary outcomes were post-operative pain scores at 2, 4, 6, 12, 18, and 24 h, total intraoperative fentanyl consumption, time to rescue analgesia, post-operative nausea vomiting, and complications, if any. Categorical data was analyzed by using the chi-squared test or Fishers Exact test. Comparison of pain scores was analyzed by using the Independent sample t test. The immediate post-operative pain scores in two groups were comparable. The pain scores were also comparable at 4, 6, 12, and 24 h; but statistically significantly lower in PECS group at 2 and 18 h. The total intraoperative fentanyl consumption was also reduced in PECS group (P = 0.009). Only 9 patients in PECS group (796.5 min) as compared to 22 patients in CONTROL group (387.7 min) required rescue analgesia (P  =  0.001). Pectoral nerve block benefits patients undergoing mastectomy by achieving similar post-operative pain scores with decreased consumption of intraoperative and post-operative opioids. Registration. Clinical Trials Registry of India, (CTRI/2017/04/008289). ctri.nic.in.

Systematic review and consensus definitions for the Standardized Endpoints in Perioperative Medicine (StEP) initiative: cardiovascular outcomes

BACKGROUND

Adverse cardiovascular events are a leading cause of perioperative morbidity and mortality. The definitions of perioperative cardiovascular adverse events are heterogeneous. As part of the international Standardized Endpoints in Perioperative Medicine initiative, this study aimed to find consensus amongst clinical trialists on a set of standardised and valid cardiovascular outcomes for use in future perioperative clinical trials.

METHODS

We identified currently used perioperative cardiovascular outcomes by a systematic review of the anaesthesia and perioperative medicine literature (PubMed/Ovid, Embase, and Cochrane Library). We performed a three-stage Delphi consensus-gaining process that involved 55 clinician researchers worldwide. Cardiovascular outcomes were first shortlisted and the most suitable definitions determined. These cardiovascular outcomes were then assessed for validity, reliability, feasibility, and clarity.

RESULTS

We identified 18 cardiovascular outcomes. Participation in the three Delphi rounds was 100% (n=19), 71% (n=55), and 89% (n=17), respectively. A final list of nine cardiovascular outcomes was elicited from the consensus: myocardial infarction, myocardial injury, cardiovascular death, non-fatal cardiac arrest, coronary revascularisation, major adverse cardiac events, pulmonary embolism, deep vein thrombosis, and atrial fibrillation. These nine cardiovascular outcomes were rated by the majority of experts as valid, reliable, feasible, and clearly defined.

CONCLUSIONS

These nine consensus cardiovascular outcomes can be confidently used as endpoints in clinical trials designed to evaluate perioperative interventions with the goal of improving perioperative outcomes.

Influence of personalised music and ice-tea options on post-operative well-being in the post anaesthesia care unit after general or regional anaesthesia. A pre-post-analysis by means of a questionnaire

OBJECTIVES

Assessment whether patients' wellbeing and disturbances in the post anaesthesia care unit could be influenced by the consecutive introduction of initially personalised music and then additionally various drink options.

DESIGN/SETTING

A pre-post-analysis by means of an anonymised survey with a validated questionnaire in a university hospital in central Europe.

MAIN OUTCOME MEASURES

Wellbeing and disturbances in the post anaesthesia care unit.

RESULTS

Patients' most frequently reported early postsurgical disturbances (n = 1335) were lack of wellbeing, dry mouth and pain in the surgical area. Reported rates of clinically relevant wellbeing were not statistically different in patients that were offered personalised music (46.5%) or additionally ice-tea (50.6%). No correlation could be found between wellbeing or physical discomfort and headphones or when ice-tea were offered.

CONCLUSION

After a decade of increased efforts to improve patients' wellbeing in the postanaesthesia care unit we could not show further influence on it by the introduction of personalised music and ice-tea. We see the need for a more differentiated focus on this topic and the need for exploratory studies on patient perception. The most frequent claims were related to lack of wellbeing, pain in the surgical area and a dry mouth.

Erector spinae plane block combined with local infiltration analgesia for total hip arthroplasty: A randomized, placebo controlled, clinical trial

The erector spinae plane block is an emerging analgesic technique, which is gaining popularity for a large number of procedures. The majority of publications are at the thoracic level and almost all indicate some benefit to patients. However, there have been relatively few randomized controlled trials and even fewer studies at the lumbar level. The aim of this study was to assess whether the erector spinae plane block at the lumbar level would confer early analgesic benefits and improve the quality of recovery in patients undergoing elective unilateral primary hip arthroplasty. Sixty-four patients were randomized to receive an erector spinae plane block at the third lumbar vertebra with either 30milliliters (ml) of 0.2% ropivacaine or 30 ml of 0.9% saline. The patient, anesthetist and assessor were blinded to allocation. The primary outcome was pain on movement at 6 h (numeric rating scale 0-10) with a reduction of 2 points considered clinically significant. Secondary outcomes included quality of recovery (QoR-15 score), mobilization and length of stay. In this study there was no appreciable analgesic benefit to adding an erector spinae plane block to patients who already receive neuraxial blocks, local anesthetic infiltration and oral multimodal analgesia for elective primary total hip arthroplasty. Both groups were found to have relatively low pain scores and a high quality of recovery with no significant difference in mobilization or length of stay.

Impact of perioperative intravenous lidocaine infusion on postoperative pain and rapid recovery of patients undergoing gastrointestinal tumor surgery: a randomized, double-blind trial

Background

To explore the effect of perioperative intravenous lidocaine infusion on postoperative pain and the rapid recovery of patients undergoing gastrointestinal tumor surgery.

Methods

The patients who underwent gastrointestinal tumor surgery from May to July 2020 were selected. The patients were randomly divided into the lidocaine group (group L) and control group (group C) by the random number table method, with 60 patients in each group. Both groups of patients received an intravenous drug infusion immediately after induction of tracheal intubation under general anesthesia. In group L, 1.5 mg/kg lidocaine was slowly injected intravenously at a rate of 1.5 mg·kg^-1·h^-1 to the surgical suture, and intravenous inhalation was used to maintain the depth of anesthesia. Group C patients were given the same volume of normal saline. The 2-, 4-, 7-, 14-, 30-, and 90-day numerical rating scale (NRS) and the proportion of chronic post-surgical pain (CPSP) after 3 months for both groups after surgery were recorded. Each patient's postoperative comfort score, requiring analgesia, return of flatus, bowl movement, hospitalization days, hospitalization expenses, and adverse events were also recorded.

Results

One hundred and twenty patients were enrolled but 5 of them failed to complete the treatment process. Therefore, 58 and 57 patients in group L and C were included into the final analysis. The NRS of patients in group L was significantly lower than that of group C at all time points after surgery (P<0.05), and the proportion of CPSP in group L was significantly lower than that of group C (P<0.05). The percentage of patients requiring analgesia and postoperative comfort score of group L was significantly higher than that of group C (P<0.01), patient's return of flatus, bowl movement, hospitalization days, and hospitalization expenses in group L were significantly lower than those in group C (P<0.05). There were no difference of adverse events between the 2 groups (P>0.05).

Conclusions

During the perioperative period of radical gastrointestinal tumor surgery, intravenous lidocaine infusion can reduce acute postoperative pain, promote postoperative gastrointestinal function recovery, and improve postoperative comfort.

Comparing erector spinae plane block with serratus anterior plane block for minimally invasive thoracic surgery: a randomised clinical trial

BACKGROUND

Minimally invasive thoracic surgery causes significant postoperative pain. Erector spinae plane (ESP) block and serratus anterior plane (SAP) block promise effective thoracic analgesia compared with systemically administered opioids, but have never been compared in terms of terms of quality of recovery and overall morbidity after minimally invasive thoracic surgery.

METHODS

Sixty adult patients undergoing minimally invasive thoracic surgery were randomly assigned to receive either single-shot ESP or SAP block before surgery using levobupivacaine 0.25%, 30 ml. The primary outcome was quality of patient recovery at 24 h, using the Quality of Recovery-15 (QoR-15) scale. Secondary outcomes included area under the curve (AUC) of pain verbal rating scale (VRS) over time, time to first opioid analgesia, postoperative 24 h opioid consumption, in-hospital comprehensive complication index (CCI) score and hospital stay.

RESULTS

The QoR-15 score was higher among ESP patients compared with those in the SAP group, mean (standard deviation): 114 (16) vs 102 (22) (P=0.02). Time (min) to first i.v. opioid analgesia in recovery was 32.6 (20.6) in ESP vs 12.7 (9.5) in SAP (P=0.003). AUC at rest was 92 (31) mm h-1vs 112 (35) in ESP and SAP (P=0.03), respectively, whereas AUC on deep inspiration was 107 mm h-1 (32) vs 129 (32) in ESP and SAP (P=0.01), respectively. VRS pain on movement in ESP and SAP at 24 h was, median (25-75% range): 4 (2-4) vs 5 (3-6) (P=0.04), respectively. Opioid consumption at 24 h postoperatively was 29 (31) vs 39 (34) (P=0.37). Median (25-75%) CCI in ESP and SAP was 1 (0-2) vs 4 (0-26) (P=0.03), whereas hospital stay was 3 (2-6) vs 6 (3-9) days (P=0.17), respectively.

CONCLUSION

Compared with SAP, ESP provides superior quality of recovery at 24 h, lower morbidity, and better analgesia after minimally invasive thoracic surgery.

CLINICAL TRIAL REGISTRATION

NCT03862612.

Patient-centred measurement of recovery from day-case surgery using wrist worn accelerometers: a pilot and feasibility study

This pilot and feasibility study evaluated wrist-worn accelerometers to measure recovery from day-case surgery in comparison with daily quality of recovery-15 scores. The protocol was designed with extensive patient and public involvement and engagement, and delivered by a research network of anaesthesia trainees. Forty-eight patients recruited through pre-operative assessment clinics wore wrist accelerometers for 7 days before (pre-operative) and immediately after elective surgery (early postoperative), and again at 3 months (late postoperative). Validated activity and quality of recovery questionnaires were administered. Raw accelerometry data were archived and analysed using open source software. The mean (SD) number of valid days of accelerometer wear per participant in the pre-operative, early and late postoperative periods were 5.4 (1.7), 6.6 (1.1) and 6.6 (1.0) days, respectively. On the day after surgery, Euclidian norm minus one (a summary measure of raw accelerations), step count, light physical activity and moderate/vigorous physical activity decreased to 57%, 47%, 59% and 35% of baseline values, respectively. Activity increased progressively on a daily basis but had not returned to baseline values by 7 days. Patient questionnaires suggested subjective recovery by postoperative day 3 to 4; however, accelerometry data showed that activity levels had not returned to baseline at this point. All activity measures had returned to baseline by 3 months. Wrist-worn accelerometery is acceptable to patients and feasible as a surrogate measure for monitoring postoperative recovery from day-case surgery. Our results suggest that patients may overestimate their rate of recovery from day-case surgery, which has important implications for future research.

Patient-reported outcomes for ambulatory surgery

PURPOSE OF REVIEW

To discuss the importance of validated tools that measure patient-reported outcomes and their use in ambulatory surgery.

RECENT FINDINGS

Sustained increases in ambulatory surgical care reflect advances in surgical techniques and perioperative anaesthetic care. Use of patient-reported outcomes allows identification of minor adverse events that are more common in this population compared with traditional endpoints such as mortality. Variability in reported outcomes restricts research potential and limits the ability to benchmark providers. The standardized endpoints in perioperative medicine initiative's recommendations on patient-reported outcomes and patient comfort measures are relevant to evaluating ambulatory care. Combining validated generic and disease-specific patient-reported outcome measures (PROMs) examines the widest spectrum of outcomes. Technological advances can be used to facilitate outcome measurement in ambulatory surgery with digital integration optimizing accurate real-time data collection. Telephone or web-based applications for reviewing ambulatory patients were found to be acceptable in multiple international settings and should be harnessed to allow remote follow-up.

SUMMARY

Use of validated tools to measure patient-reported outcomes allows internal and external quality comparison. Tools can be combined to measure objective outcomes and patient satisfaction. These are both key factors in driving forward improvements in perioperative ambulatory surgical care.

Developing consensus on core outcome domains and measurement instruments for assessing effectiveness in perioperative pain management after sternotomy, breast cancer surgery, total knee arthroplasty, and surgery related to endometriosis : The IMI-PainCare PROMPT protocol for achieving a consensus on core outcome domains

INTRODUCTION

Evidence synthesis of clinical trials requires consistent outcome assessment. For pain management after surgery, inconsistency of effectiveness assessment is still observed. A subproject of IMI-PainCare (Innovative Medicine Initiatives, www.imi-paincare.eu ) aims for identifying core outcome domains and measurement instruments for postoperative pain in four surgical fields (sternotomy, breast cancer surgery, total knee arthroplasty, and surgery related to endometriosis) in order to harmonize outcome assessment for perioperative pain management.

METHODS

A multifaceted process will be performed according to existing guidelines (Core Outcome Measures in Effectiveness Trials (COMET), COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)). In a first step, outcome domains will be identified via systematic literature review and consented on during a 1-day consensus meeting by 10 stakeholder groups, including patient representatives, forming an IMI PROMPT consensus panel. In a second step, outcome measurement instruments regarding the beforehand consented core outcome domains and their psychometric properties will be searched for via systematic literature review and approved by COSMIN checklist for study quality and scale quality separately. In a three-step online survey, the IMI PROMPT consensus panel will vote for most suitable measurement instruments. The process is planned to be conducted between 11/2017 (systematic literature review on common outcome domains) and 3/2022 (final voting on core outcome measurement).

Patient-maintained propofol sedation for adult patients undergoing surgical or medical procedures: a scoping review of current evidence and technology

Patient-maintained propofol sedation (PMPS) is the delivery of procedural propofol sedation by target-controlled infusion with the patient exerting an element of control over their target-site propofol concentration. This scoping review aims to establish the extent and nature of current knowledge regarding PMPS from both a clinical and technological perspective, thereby identifying knowledge gaps to guide future research. We searched MEDLINE, EMBASE, and OpenGrey databases, identifying 17 clinical studies for analysis. PMPS is described in the context of healthy volunteers and in orthopaedic, general surgical, dental, and endoscopic clinical settings. All studies used modifications to existing commercially-available infusion devices to achieve prototype systems capable of PMPS. The current literature precludes rigorous generalisable conclusions regarding the safety or comparative clinical effectiveness of PMPS, however cautious acknowledgement of efficacy in specific clinical settings is appropriate. Based on the existing literature, together with new standardised outcome reporting recommendations for sedation research and frameworks designed to assess novel health technologies research, we have made recommendations for future pharmacological, clinical, behavioural, and health economic research on PMPS. We conclude that high-quality experimental clinical trials with relevant comparator groups assessing the impact of PMPS on standardised patient-orientated outcome measures are urgently required.

Is the minimal clinically important difference (MCID) in acute pain a good measure of analgesic efficacy in regional anesthesia?

In the field of acute pain medicine research, we believe there is an unmet need to incorporate patient related outcome measures that move beyond reporting pain scores and opioid consumption. The term “minimal clinically important difference” (MCID) defines the clinical benefit of an intervention as perceived by the patient, as opposed to a mathematically determined statistically significant difference that may not necessarily be clinically significant. The present article reviews the concept of MCID in acute postoperative pain research, addresses potential pitfalls in MCID determination and questions the clinical validity of extrapolating MCID determined from chronic pain and non-surgical pain studies to the acute postoperative pain setting. We further suggest the concepts of minimal clinically important improvement, substantial clinical benefit and patient acceptable symptom state should also represent aspirational outcomes for future research in acute postoperative pain management.

A systematic review of outcomes reported inpediatric perioperative research: A report from the Pediatric Perioperative Outcomes Group

The Pediatric Perioperative Outcomes Group (PPOG) is an international collaborative of clinical investigators and clinicians within the subspecialty of pediatric anesthesiology and perioperative care which aims to use COMET (Core Outcomes Measures in Effectiveness Trials) methodology to develop core outcome setsfor infants, children and young people that are tailored to the priorities of the pediatric surgical population.Focusing on four age-dependent patient subpopulations determined a priori for core outcome set development: i) neonates and former preterm infants (up to 60 weeks postmenstrual age); ii) infants (>60 weeks postmenstrual age - <1 year); iii) toddlers and school age children (>1-<13 years); and iv) adolescents (>13-<18 years), we conducted a systematic review of outcomes reported in perioperative studies that include participants within age-dependent pediatric subpopulations. Our review of pediatric perioperative controlled trials published from 2008 to 2018 identified 724 articles reporting 3192 outcome measures. The proportion of published trials and the most frequently reported outcomes varied across pre-determined age groups. Outcomes related to patient comfort, particularly pain and analgesic requirement, were the most frequent domain for infants, children and adolescents. Clinical indicators, particularly cardiorespiratory or medication-related adverse events, were the most common outcomes for neonates and infants < 60 weeks and were the second most frequent domain at all other ages. Neonates and infants <60 weeks of age were significantly under-represented in perioperative trials. Patient-centered outcomes, heath care utilization, and bleeding/transfusion related outcomes were less often reported. In most studies, outcomes were measured in the immediate perioperative period, with the duration often restricted to the post-anesthesia care unit or the first 24 postoperative hours. The outcomes identified with this systematic review will be combined with patient centered outcomes identified through a subsequent stakeholder engagement study to arrive at a core outcome set for each age-specific group.

Intra-operative methadone effect on quality of recovery compared with morphine following laparoscopic gastroplasty: a randomised controlled trial

The effect of intra-operative intravenous methadone on quality of postoperative recovery was compared with morphine after laparoscopic gastroplasty. We included 137 adult patients with a body mass index > 35 kg.m^-2 who underwent bariatric surgery. Patients were allocated at random to receive either intra-operative methadone (n = 69) or morphine (n = 68). All patients received the same postoperative care and analgesia. The primary outcome of postoperative quality of recovery was assessed using the Quality of Recovery-40 questionnaire total score 24 h after surgery. Secondary outcomes were assessed in the post-anaesthesia care unit the night of the day of surgery (T1), in the morning after surgery (T2); and at night on the day following surgery (T3). The median (IQR [range]) total Quality of Recovery-40 questionnaire score of 194 (190-197 [165-200]) was higher (p < 0.0001) in the methadone group compared with the score of 181 (174-185.5 [121-200]) in the morphine group. In the post-anaesthesia care unit, the pain burden; incidence of nausea and vomiting; rescue morphine dose; and time to discharge, were significantly lower in the methadone group. On the ward, the methadone group had a lower: incidence of rescue morphine requests at T1 (5.8 vs. 54.4%, p < 0.0001) and T2 (0 vs. 20.1%, p < 0.0001); and incidence of nausea (21.7 vs. 41.2%, p = 0.014), compared with the morphine group. We conclude that intra-operative intravenous methadone improved quality of recovery in patients who underwent laparoscopic gastroplasty, compared with intra-operative morphine. Methadone also reduced postoperative pain, postoperative opioid consumption and the incidence of opioid-related adverse events.

The Effect of a Small Priming Dose of Sufentanil on Sufentanil-Induced Cough

PURPOSE

The aim of this study was to investigate the effect of a small priming dose of sufentanil on sufentanil-induced cough during induction of anesthesia.

DESIGN

Randomized controlled trial.

METHODS

Adult patients (N = 220) aged 18 to 65 years undergoing general anesthesia were randomized into two groups (n = 110), a total dose of sufentanil 0.4 mcg/kg was used during induction of anesthesia. Group P (intervention) received a bolus of 5 mcg of sufentanil 1 minute before a bolus of the remaining larger dose of sufentanil, whereas group C (comparison) received an equal volume of normal saline 1 minute before a bolus of the total dose of sufentanil. The incidence and severity of cough were noted for 1 minute after each injection of sufentanil or normal saline.

FINDINGS

The incidence of cough in group P was significantly lower than group C (6.4% vs 21.8%, P < .001). The severity of cough in group P was significantly decreased compared with group C (P < .001). In group P, three patients (2.7%, P = .247) coughed after the priming sufentanil injection.

CONCLUSIONS

A priming dose of 5 mcg of sufentanil 1 minute before a larger dose of sufentanil injection could effectively alleviate sufentanil-induced cough, the small priming dose of sufentanil could also elicit cough with a low incidence.

Perioperative Use of Gabapentinoids for the Management of Postoperative Acute Pain

Background

Widely used for acute pain management, the clinical benefit from perioperative use of gabapentinoids is uncertain. The aim of this systematic review was to assess the analgesic effect and adverse events with the perioperative use of gabapentinoids in adult patients.

Methods

Randomized controlled trials studying the use of gabapentinoids in adult patients undergoing surgery were included. The primary outcome was the intensity of postoperative acute pain. Secondary outcomes included the intensity of postoperative subacute pain, incidence of postoperative chronic pain, cumulative opioid use, persistent opioid use, lengths of stay, and adverse events. The clinical significance of the summary estimates was assessed based on established thresholds for minimally important differences.

Results

In total, 281 trials (N = 24,682 participants) were included in this meta-analysis. Compared with controls, gabapentinoids were associated with a lower postoperative pain intensity (100-point scale) at 6 h (mean difference, −10; 95% CI, −12 to −9), 12 h (mean difference, −9; 95% CI, −10 to −7), 24 h (mean difference, −7; 95% CI, −8 to −6), and 48 h (mean difference, −3; 95% CI, −5 to −1). This effect was not clinically significant ranging below the minimally important difference (10 points out of 100) for each time point. These results were consistent regardless of the type of drug (gabapentin or pregabalin). No effect was observed on pain intensity at 72 h, subacute and chronic pain. The use of gabapentinoids was associated with a lower risk of postoperative nausea and vomiting but with more dizziness and visual disturbance.

Conclusions

No clinically significant analgesic effect for the perioperative use of gabapentinoids was observed. There was also no effect on the prevention of postoperative chronic pain and a greater risk of adverse events. These results do not support the routine use of pregabalin or gabapentin for the management of postoperative pain in adult patients.

Editor’s Perspective

What We Already Know about This Topic

What This Article Tells Us That Is New

A systematic review of pain outcomes reported by randomised trials of hip and knee arthroplasty

It is difficult to pool results from randomised clinical trials that report different outcomes. We want to develop a core set of pain-related outcomes after total hip or knee arthroplasty, the first stage of which is to systematically review published outcomes. We searched PubMed, Embase and CENTRAL for relevant trials to January 2020. We identified 165 outcomes from 565 trials with 50,668 participants, which we categorised into six domains: pain; analgesic consumption; quality of care; adverse events; mobility; and patient-reported outcome measures. The outcome in each domain reported by most trials was: visual analogue score for pain, 401 (71%); morphine consumption, 212 (38%); length of hospital stay, 166 (29%); nausea or vomiting, 425 (75%); range of motion, 173 (31%); and patient satisfaction score, 181 (32%). A primary outcome was reported in 281 (50%) trials: 101 (18%) trials reported consumption of rescue analgesics and 95 (17%) trials reported pain. We plan to publish a consensus on outcomes that should be reported in postoperative pain trials after hip or knee arthroplasty.

Enhanced Recovery after Lumbar Spine Fusion

Background

Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion.

Methods

A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein).

Results

The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (−3 h; 95% CI, −6, −0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (−11 h; 95% CI, −19, −6; P &lt; 0.001) were shorter; opioid consumption was lower at day 1 (−57 mg; 95% CI, −130, −5; P = 0.030) without adversely affecting pain scores (−2; 95% CI, −3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037).

Conclusions

Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

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Pediatric perioperative outcomes: Protocol for a systematic literature review and identification of a core outcome set for infants, children, and young people requiring anesthesia and surgery

Clinical outcomes are measurable changes in health, function, or quality of life that are important for evaluating the quality of care and comparing the efficacy of interventions. However, clinical outcomes and related measurement tools need to be well-defined, relevant, and valid. In adults, Core Outcome Measures in Effectiveness Trials (COMET) methodology has been used to develop core outcome sets for perioperative care. Systematic literature reviews identified standardized endpoints (StEP) and valid measurement tools, and consensus across a broader range of relevant stakeholders was achieved via a Delphi process to establish Core Outcome Measures in Perioperative and Anaesthetic Care (COMPAC). Core outcome sets for pediatric perioperative care cannot be directly extrapolated from adult data. The type and weighting of endpoints within particular domains can be influenced by age-dependent differences in the indications for and/or nature of surgery and medical comorbidities, and the validity and utility of many measurement tools vary significantly with developmental stage and age. The involvement of parents/carers is essential as they frequently act as surrogate responders for preverbal and developmentally delayed children, parental response may influence child outcome, and parental and/or child ranking of outcomes may differ from those of health professionals. Here, we describe the formation of the international Pediatric Perioperative Outcomes Group, which aims to identify and create validated, broadly applicable, patient-centered outcome measures for infants, children, and young people. Methodologies parallel that of the StEP and COMPAC projects, and systematic literature searches have been performed within agreed age-dependent subpopulations to identify reported outcomes and measurement tools. This represents the first steps for developing core outcome sets for pediatric perioperative care.

Effects of epidural combined with general anesthesia versus general anesthesia on quality of recovery of elderly patients undergoing laparoscopic radical resection of colorectal cancer: A prospective randomized trial

STUDY OBJECTIVES

The aim of the present study was to assess the quality of recovery from anesthesia on patients subjected to laparoscopic radical resection of colorectal cancer under epidural block combined with general anesthesia or general anesthesia by means of Quality of Recovery-15 (QoR-15) questionnaire.

DESIGN

Prospective randomized trial.

SETTING

The setting is at an operating room, a post-anesthesia care unit, and a hospital ward.

PATIENTS

Seventy patients, aging from 65 to 79 years with an American Society of Anesthesiologists physical status II or III, were scheduled to undergo laparoscopic radical resection of colorectal cancer.

INTERVENTIONS

Epidural block combined with general anesthesia or general anesthesia.

MEASUREMENTS

The QoR-15 was administered by an investigator blind to group allocation before surgery (T₀), at 24 and 72h after surgery (T₁ and T₂), and on postoperative day 7 (T₃). The quality of recovery, as assessed by the score on the QoR-15, was compared between the groups. Besides, the consumption of anesthetics, respiratory recovery time, response time, extubation time, flatus time, the incidence of nausea or vomiting, the consumption of antiemetic and analgesic agents, and the duration of the hospital stay were also recorded.

MAIN RESULTS

The QoR-15 scores at T₁ and T₂ were significantly higher in the E + G group compared with the G group (P < 0.05). Among the five dimensions of the QoR-15, physiological comfort, physiological independence, pain, and emotional dimension were significantly better at T₁ in the E + G group, and physiological comfort and pain were significantly better at T₂ in the E + G group.

CONCLUSION

This study demonstrates that epidural block combined with general anesthesia can improve the early recovery of elderly patients after laparoscopic radical resection of colorectal cancer from the perspective of patients.

Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome?

PURPOSE OF REVIEW

Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery.

RECENT FINDINGS

Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency.

SUMMARY

Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.

Opioid versus opioid-free analgesia after surgical discharge: protocol for a systematic review and meta-analysis

INTRODUCTION

Excessive prescribing after surgery has contributed to a public health crisis of opioid addiction and overdose in North America. However, the value of prescribing opioids to manage postoperative pain after surgical discharge remains unclear. We propose a systematic review and meta-analysis to assess the extent to which opioid analgesia impact postoperative pain intensity and adverse events in comparison to opioid-free analgesia in patients discharged after surgery.

METHODS AND ANALYSIS

Major electronic databases (MEDLINE, Embase, Cochrane Library, Scopus, AMED, BIOSIS, CINAHL and PsycINFO) will be searched for multi-dose randomised-trials examining the comparative effectiveness of opioid versus opioid-free analgesia after surgical discharge. Studies published from January 1990 to July 2019 will be targeted, with no language restrictions. The search will be re-run before manuscript submission to include most recent literature. We will consider studies involving patients undergoing minor and major surgery. Teams of reviewers will, independently and in duplicate, assess eligibility, extract data and evaluate risk of bias. Our main outcomes of interest are pain intensity and postoperative vomiting. Study results will be pooled using random effects models. When trials report outcomes for a common domain (eg, pain intensity) using different scales, we will convert effect sizes to a common standard metric (eg, Visual Analogue Scale). Minimally important clinical differences reported in previous literature will be considered when interpreting results. Subgroup analyses defined a priori will be conducted to explore heterogeneity. Risk of bias will be assessed according to the Cochrane Collaboration's Risk of Bias Tool 2.0. The quality of evidence for all outcomes will be evaluated using the GRADE rating system.

ETHICS AND DISSEMINATION

Ethical approval is not required since this is a systematic review of published studies. Our results will be published in a peer-reviewed journal and presented at relevant conferences. Further knowledge dissemination will be sought via public and patient organisations focussed on pain and opioid-related harms.

Impact of Local Infiltration Analgesia on the Quality of Recovery After Anterior Total Hip Arthroplasty: A Randomized, Triple-Blind, Placebo-Controlled Trial

BACKGROUND

Local infiltration analgesia (LIA) is commonly used in anterior total hip arthroplasty (THA) surgery; however, evidence for its efficacy is lacking. We hypothesized that LIA with 0.2% ropivacaine when compared with injection of placebo (0.9% saline) would improve patient quality of recovery on postoperative day (POD) 1, as measured by the Quality of Recovery-15 (QoR-15) score.

METHODS

Patients scheduled to have a primary unilateral anterior THA with a single surgeon in a tertiary level metropolitan hospital were randomized to receive LIA with either 2.5 mL/kg of 0.2% ropivacaine or 0.9% saline as placebo. Patients and clinical and study personnel were blinded to group allocation. Perioperative care was standardized and this included spinal anesthesia and oral multimodal analgesia. The primary outcome was a multidimensional (pain, physical comfort, physical independence, emotions, and psychological support) patient-reported quality of recovery scale, QoR-15, measured on POD 1.

RESULTS

One hundred sixty patients were randomized; 6 patients were withdrawn after randomization and 2 patients had incomplete outcome data. The intention-to-treat analysis included 152 patients. The median (interquartile range [IQR]) QoR-15 score on POD 1 of the ropivacaine group was 119.5 (102-124), compared with the placebo group which had a median (IQR) of 115 (98-126). The median difference of 2 (95% confidence interval [CI], -4 to 7; P = .56) was not statistically or clinically significant. An as-per-protocol sensitivity analysis of 146 patients who received spinal anesthesia without general anesthesia, and the allocated intervention, also showed no evidence of a significant difference between groups. Secondary outcomes (worst pain numerical rating scale at rest and with movement on POD 1, opioid consumption on PODs 1 and 2, mobilization on POD 1, Brief Pain Inventory severity and interference on POD 90, and length of stay) were similar in both groups.

CONCLUSIONS

LIA with 0.2% ropivacaine when compared with 0.9% saline as placebo did not improve quality of recovery 1 day after anterior THA.

Ultrasound-guided bilateral superficial cervical plexus blocks enhance the quality of recovery in patients undergoing thyroid cancer surgery: A randomized controlled trial

STUDY OBJECTIVE

Regional anesthesia can improve postoperative analgesia and enhance the quality of recovery (QoR) after surgery. This trial evaluates the effects of ultrasound-guided bilateral superficial cervical plexus block (SCPB) on QoR in patients undergoing thyroid cancer surgery.

DESIGN

Prospective, randomized, double-blinded, placebo-controlled trial.

SETTING

Operating room.

PATIENTS

Seventy-four ASA I-II female patients scheduled for thyroid cancer surgery were included to the study.

INTERVENTIONS

Patients were randomly allocated to receive pre-operative ultrasound-guided bilateral SCPB with 10 ml of ropivacaine 0.5% or normal saline on each side.

MEASUREMENTS

The primary endpoint was the quality of recovery, which was assessed using the 15-item quality of recovery questionnaire (QoR-15). Secondary endpoints were acute postoperative pain, time to first rescue analgesia, the number of patients requiring rescue analgesia, length of post-anesthesia care unit (PACU) stay, the incidence of postoperative nausea or vomiting (PONV) and dizziness, and patient satisfaction.

MAIN RESULTS

The global QoR-15 score at 24 h postoperatively was significantly higher in the SCPB group (Median [IQR], 118 [115-120]) than the control group (110 [106-112]) with a median difference of 8 (95% CI: 6 to 10, P < .001). Compared with the control group, pre-operative ultrasound-guided bilateral SCPB reduced postoperative pain up to 24 h and the incidence of PONV, as well as the length of PACU stay. Additionally, the patient satisfaction scores were improved in the SCPB group (P = .024).

CONCLUSION

Pre-operative ultrasound-guided bilateral SCPB with ropivacaine enhances the quality of recovery, postoperative analgesia and patient satisfaction, alleviates the incidence of PONV, and accelerates the PACU discharge following thyroid cancer surgery.

Protocol for a multicentre retrospective observational cohort study in Denmark: association between the intraoperative peripheral perfusion index and postoperative morbidity and mortality in acute non-cardiac surgical patients

INTRODUCTION

Perioperative haemodynamic instability is associated with postoperative morbidity and mortality. Macrocirculatory parameters, such as arterial blood pressure and cardiac output are associated with poor outcome but may be uncoupled from the microcirculation during sepsis and hypovolaemia and may not be optimal resuscitation parameters. The peripheral perfusion index (PPI) is derived from the pulse oximetry signal. Reduced peripheral perfusion is associated with morbidity in critically ill patients and in patients following acute surgery. We hypothesise that a low intraoperative PPI is independently associated with postoperative complications and mortality.

METHODS AND ANALYSIS

We plan to conduct a retrospective cohort study in approximately 2300 patients, who underwent acute non-cardiac surgery (1 November 2017 to 31 October 2018) at two Danish University Hospitals. Data will be collected from patient records including patient demographics, comorbidity and intraoperative haemodynamic values with PPI as the primary exposure variable, and postoperative complications and mortality within 30 and 90 days as outcome variables. We primarily assess association between PPI and outcome in multivariate regression models. Second, the predictive value of PPI for outcome, using area under the receiver operating characteristics curve is assessed.

ETHICS AND DISSEMINATION

Data will be reported according to the Strengthening the Reporting of Observational Studies in Epidemiology and results published in a peer-reviewed journal. The study is approved by the regional research ethics committee, storage and management of data has been approved by the Regional Data Protection Agency, and access to medical records is approved by the hospital board of directors (ClinicalTrials.gov registration no: NCT03757442).