Local anesthetics (LAs) are commonly infiltrated into surgical wounds for postsurgical analgesia. While many adjuncts to LA agents have been studied, it is unclear which adjuncts are most effective for co-infiltration to improve and prolong analgesia. We performed a systematic review on adjuncts (excluding epinephrine) to local infiltrative anesthesia to determine their analgesic efficacy and opioid-sparing properties. Multiple databases were searched up to December 2019 for randomized controlled trials (RCTs) and two reviewers independently performed title/abstract screening and full-text review. Inclusion criteria were (1) adult surgical patients and (2) adjunct and LA agents infiltration into the surgical wound or subcutaneous tissue for postoperative analgesia. To focus on wound infiltration, studies on intra-articular, peri-tonsillar, or fascial plane infiltration were excluded. The primary outcome was reduction in postoperative opioid requirement. Secondary outcomes were time-to-first analgesic use, postoperative pain score, and any reported adverse effects. We screened 6670 citations, reviewed 126 full-text articles, and included 89 RCTs. Adjuncts included opioids, non-steroidal anti-inflammatory drugs, steroids, alpha-2 agonists, ketamine, magnesium, neosaxitoxin, and methylene blue. Alpha-2 agonists have the most evidence to support their use as adjuncts to LA infiltration. Fentanyl, ketorolac, dexamethasone, magnesium and several other agents show potential as adjuncts but require more evidence. Most studies support the safety of these agents. Our findings suggest benefits of several adjuncts to local infiltrative anesthesia for postoperative analgesia. Further well-powered RCTs are needed to compare various infiltration regimens and agents.Protocol registrationPROSPERO (CRD42018103851) (https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=103851)
Smokers are at increased risk for surgical complications. Despite the known benefits of smoking cessation, many perioperative health care providers do not routinely provide smoking cessation interventions. The variation in delivery of perioperative smoking cessation interventions may be due to limited high-level evidence for whether smoking cessation interventions used in the general population are effective and feasible in the surgical population, as well as the challenges and barriers to implementation of interventions. Yet smoking is a potentially modifiable risk factor for improving short- and long-term patient outcomes. The purpose of the Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement on Perioperative Smoking Cessation is to present recommendations based on current scientific evidence in surgical patients. These statements address questions regarding the timing and intensity of interventions, roles of perioperative health care providers, and behavioral and pharmacological interventions. Barriers and strategies to overcome challenges surrounding implementation of interventions and future areas of research are identified. These statements are based on the current state of knowledge and its interpretation by a multidisciplinary group of experts at the time of publication.
There is a growing interest in multimodal prehabilitation programs prior to surgery. Several recent guidelines have recommended multimodal prehabilitation programs that include smoking cessation. While preoperative smoking cessation programs reduce perioperative complications and increase long-term abstinence, 1 the impact of smoking cessation interventions as part of multimodal prehabilitation programs has not been described. As such, we performed a systematic review to summarize the literature on prehabilitation programs that have included smoking cessation.A literature search was performed in April 2018 of Medline, Medline In-Process, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PubMed-NOT-Medline, CINAHL, Web of Science, and Scopus. Studies that evaluated the effect of preoperative smoking cessation as part of surgical prehabilitation were included.The literature search identified seven studies for inclusion (Table). Five studies were observational studies and two were randomized-controlled trials. The study populations included patients undergoing elective thoracic, abdominal, and orthopedic surgeries. Interventions generally consisted of a combination of aerobic exercise, strength training, pulmonary rehabilitation, and lifestyle modification including smoking cessation.Five studies assessed the effect of their interventions on postoperative outcomes. Three studies found an improvement in outcomes, primarily a reduction in postoperative pulmonary complications and hospital length of stay; however, two other studies failed to show a reduction in postoperative pulmonary complications.Three studies examined the effect of the intervention on exercise capacity and health-related quality of life. The results show that the interventions can effectively improve exercise capacity; however, the results for quality of life were inconsistent.Three studies reported the number of current smokers undergoing the intervention that quit smoking preoperatively, with abstinence rates from 46-100%. The results show that the interventions resulted in a high smoking abstinence rate prior to surgery; however, longterm abstinence was not measured in any of the studies.Even though the evidence suggests some beneficial effects, the evidence for smoking cessation interventions in the context of multimodal prehabilitation programs is limited. Most of the studies were observational, and only two were randomized studies with small sample sizes. The studies were heterogeneous with regards to the surgical population, types of interventions, and outcomes. Most of the studies did not start the smoking cessation intervention early enough (at least four weeks before surgery-the minimum period shown to reduce postoperative complications). 1 Most importantly, as no study compared prehabilitation programs with and without smoking cessation, we are not able to identify the specific benefits
The use of ultrasound-guided regional anesthesia (UGRA) has increased, leading to a growing demand for UGRA training [1]. Education may be particularly challenging for those already in established practice because educational opportunities are less obvious. In 2009, the American and European Societies of Regional Anesthesia published guidelines for training pathways in UGRA [2]. For practicing anesthesiologists, they recommended workshops consisting of "didactic teaching and hands-on experience [2]. " However, there is limited evidence [3] suggesting that these workshops are effective and can impact participants' clinical practice. We aimed to assess if attendance at a UGRA workshop improved confidence in block performance and impacted clinical practice. Since 2004, the regional anesthesia group at Toronto Western Hospital, University Health Network has conducted semi-annual UGRA workshops. These 2-day workshops consist of didactic lectures, live scanning of models under expert supervision, and needling practice on low fidelity simulators. The course curriculum includes teaching on upper and lower limb blocks, truncal blocks, and neuraxial ultrasound. To assess the impact of the workshop, participants were sent an online survey after completion of two courses in 2018. The primary outcome assessed with our survey was the change in participants' confidence levels post-workshop. Secondary outcomes included participants' perceptions on whether or not the workshop made a relevant impact on their clinical practice and to identify the important factors, which can increase the use of UGRA in clinical practice. Of the 99 people who participated in the two workshops, 58 (59%) responded to the follow-up survey, and 34% of the participants stated that they felt confident in performing UGRA blocks prior to attending the workshop, which increased to 66% after the workshop (P < 0.001; McNemar's test) (Fig. 1A). The major reason participants said they were not confident was the lack of needling practice (67%). Other common reasons included inadequate scanning practice (20%) and insufficient knowledge of block procedure (13%). For less experienced participants (defined as having previously performed less than 50 blocks), there was a significant increase in the percentage of participants who felt confident after the workshop. The number of confident participants in the less experienced group rose from 6% before the workshop to 61% after (P < 0.001; McNemar's test) (Fig. 1B). In contrast, more experienced participants (defined as having previously performed more than 50 blocks) showed no change in their confidence levels before and after the workshop (Fig. 1B). Most (95%) participants stated that the workshop made a relevant impact on their clin
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