SSFNB or continuous FNB (plus PCA) was found to be superior to PCA alone for postoperative analgesia for patients having total knee arthroplasty. The impact of adding a sciatic block or continuous FNB to a SSFNB needs to be studied further.

Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Purpose The success of any research process relies, in part, on how well investigators are able to translate a clinical problem into a research question-a task that is not so simple for novice investigators. The PICOT approach requires that the framing of the research question specify the target Population, the Intervention of interest, the Comparator intervention, key Outcomes, and the Time frame over which the outcomes are assessed. This paper describes the use of the PICOT structure in framing research questions and examines PICOT criteria as applied to the anesthesia literature. We also provide a roadmap for applying the PICOT format in identifying and framing clear research questions. Methods In addition to searching MEDLINE for the literature on framing research questions, we performed a systematic review of articles published in four key anesthesia journals in 2006, including Anesthesiology, Anesthesia & Analgesia, the British Journal of Anaesthesia, and the Canadian Journal of Anesthesia. Results Three hundred thirteen articles (n = 313) were included in this review, with the following distribution by study design: 139 (44%) randomized controlled trials, 129 (41%) cohort studies, and 45 (15%) case-controlled, crosssectional studies or systematic reviews. Overall, 96% (95% confidence interval: 91,100) of articles did not apply the PICOT approach in reporting the research question. Conclusions The PICOT approach may be helpful in defining and clearly stating the research question. It remains to be determined whether or not compliance with the PICOT style, or any other format for framing research questions, is associated with a higher quality of research reporting. RésuméObjectif La re´ussite de tout processus de recherche s'appuie en partie sur la capacite´des chercheurs a`traduire un proble`me clinique en question de recherche, une taˆche ardue pour les chercheurs de´butants. L'approche PICOT exige que la formulation de la question de recherche spe´cifie la Population cible, l'Intervention al 'e´tude, l'intervention de Comparaison, les devenirs cle´s (Outcomes) et un cadre Temporel au cours duquel les devenirs sont e´value´s. Cet article de´crit l'utilisation de la structure PICOT dans la formulation des questions de recherche et examine les crite`res PICOT lorsqu'ils sont applique´s à la litte´rature en anesthe´sie. Nous fournissons e´galement une feuille de route visant a`l'application du format PICOT pour identifier et formuler des questions de recherche claires. Méthode En plus de recherches sur MEDLINE pour trouver la litte´rature touchant a`la formulation de questions de recherche, nous avons effectue´une re´vision

Background The effect on cardiovascular outcomes of withholding angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers in chronic users before noncardiac surgery is unknown. Methods In this international prospective cohort study, the authors analyzed data from 14,687 patients (including 4,802 angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users) at least 45 yr old who had in-patient noncardiac surgery from 2007 to 2011. Using multivariable regression models, the authors studied the relationship between withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers and a primary composite outcome of all-cause death, stroke, or myocardial injury after noncardiac surgery at 30 days, with intraoperative and postoperative clinically important hypotension as secondary outcomes. Results Compared to patients who continued their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, the 1,245 (26%) angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker users who withheld their angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers in the 24 h before surgery were less likely to suffer the primary composite outcome of all-cause death, stroke, or myocardial injury (150/1,245 [12.0%] vs. 459/3,557 [12.9%]; adjusted relative risk, 0.82; 95% CI, 0.70 to 0.96; P = 0.01) and intraoperative hypotension (adjusted relative risk, 0.80; 95% CI, 0.72 to 0.93; P < 0.001). The risk of postoperative hypotension was similar between the two groups (adjusted relative risk, 0.92; 95% CI, 0.77 to 1.10; P = 0.36). Results were consistent across the range of preoperative blood pressures. The practice of withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers was only modestly correlated with patient characteristics and the type and timing of surgery. Conclusions Withholding angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers before major noncardiac surgery was associated with a lower risk of death and postoperative vascular events. A large randomized trial is needed to confirm this finding. In the interim, clinicians should consider recommending that patients withhold angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers 24 h before surgery.

Purpose: Gabapentin's role in the treatment of chronic neuropathic pain is well known. What is less well established is its role for managing postoperative pain. In order to clarify whether gabapentin's utility in acute pain control is more than just theoretical, we conducted a meta-analysis of all randomized trials that addressed gabapentin's role in acute postoperative pain control. We specifically addressed whether gabapentin reduces pain scores, analgesia consumption, and/or analgesia-related side effects in the first 24 hr following surgery. Source:We identified eight placebo-controlled, randomized controlled trials and conducted a meta-analysis using the primary outcomes of pain scores, total analgesia consumption, and side effects over a 24-hr period. Principle findings:Patients who received gabapentin preoperatively reported significantly lower pain scores (-11.9 at rest and -11.0 with movement on a 100-point visual analogue scale) and opioid consumption (-14.7 mg of morphine in 24 hr) with no difference in the incidence of side effects. Conclusion:Although gabapentin given preoperatively decreases pain scores and analgesic consumption in the first 24 hr after surgery, the clinical significance of this finding has yet to be determined. This meta-analysis could not demonstrate a significant reduction in the incidence of side effects. Due to the small numbers enrolled in the studies, larger randomized control trials are warranted. Objectif : Le rôle de la gabapentine dans le traitement de la douleur neuropathique chronique est bien connu. Ce qui l'est moins, c'est son rôle dans le traitement de la douleur postopératoire. Pour le vérifier, nous avons fait une méta-analyse de toutes les études randomisées qui ont abordé le rôle de la gabapentine dans le contrôle de la douleur postopératoire aiguë. Nous avons surtout cherché si la gabapentine réduit les scores de douleur, la consommation d'analgésique et/ou les effets secondaires reliés à l'analgésie des 24 premières heures postopératoires. Source : Nous avons repéré huit études randomisées, contrôlées contre placebo et mené une méta-analyse en utilisant les principaux paramètres des scores de douleur, consommation totale d'analgésique et effets secondaires pendant 24 h.Constatations principales : Les patients qui ont reçu de la gabapentine préopératoire ont présenté des scores de douleur (-11,9 au repos et -11,0

Gabapentin 600 mg po given preoperatively followed by 200 mg po every eight hours for two days has no effect on postoperative morphine consumption, pain scores, patient satisfaction, or length of hospital stay. This trial is registered at ClinicalTrials.gov NCT01307202.

Purpose The primary objectives of this historical casecontrol study were to evaluate the incidence of and reasons and risk factors for adult unanticipated admissions in three tertiary care Canadian hospitals following ambulatory surgery. Methods A random sample of 200 patients requiring admission (cases) and 200 patients not requiring admission (controls) was taken from 20,657 ambulatory procedures was identified and compared. The following variables were included: demographics, reason for admission, type of anesthesia, surgical procedure, length of procedure, American Society of Anesthesiologists' (ASA) classification, surgical completion time, pre-anesthesia clinic, medical history, medications (classes), and perioperative complications. Multiple logistic regression analysis was used to assess factors associated with unanticipated admissions. ResultsThe incidence of unanticipated admission following ambulatory surgery was 2.67%. The most common reasons for admission were surgical (40%), anesthetic (20%), and medical (19%). The following factors were found to be associated with an increased risk of unanticipated admission: length of surgery of one to three hours (odds ratio [OR] Author contributions Amanda Whippey, Greg Kostandoff, James Paul, Jinhui Ma, and Lehana Thabane helped design the study and write the manuscript. Amanda Whippey, Greg Kostandoff, and James Paul helped conduct the study. Heung Kan Ma helped in data collection, and Jinhui Ma and Lehana Thabane helped analyze the data. James Paul is the author responsible for archiving the study files. Amanda Whippey, Greg Kostandoff, Jinhui Ma, James Paul, Lehana Thabane, and Heung Kan Ma have seen the original study data. Amanda Whippey, Greg Kostandoff, Jinhui Ma, James Paul, and Lehana Thabane reviewed the analysis of the data. 0.08 to 0.33), and dental/ear-nose-throat surgery (OR 0.32; 95% CI 0.13 to 0.83) when compared with general surgery. Other comorbid conditions did not impact unanticipated admission. Conclusion Unanticipated admission after ambulatory surgery occurs mainly due to surgical, anesthetic, and medical complications. Length of surgery more than one hour, high ASA class, advanced age, and increased BMI were all predictors. No specific comorbid illness was associated with an increased likelihood of unanticipated admission. These findings support continued use of the ASA classification as a marker of patient perioperative risk rather than attributing risk to a specific disease process. RésuméObjectif Les objectifs primaires de cette e´tude cas-te´moin historique e´taient d'e´valuer l'incidence ainsi que les raisons et les facteurs de risque des admissions non anticipe´es de patients adultes dans trois hôpitaux canadiens de soins tertiaires apre`s une chirurgie ambulatoire. dentaire / oto-rhino-larynge´e (ORL) (RC 0,32; IC 95 % 0,13 a`0,83) par rapport a`une chirurgie ge´ne´rale. Aucun impact sur les admissions non anticipe´es n'a e´te´observeá vec d'autres comorbidite´s. Conclusion Les admissions non anticipe´es apre`s une chi...

Purpose: To determine if deliberate hypotension decreases blood loss and transfusion requirements in patients undergoing orthopedic surgery, a systematic review of all randomized trials addressing this issue was undertaken.Methods: Electronic databases, citations lists and review articles were searched for potential articles. Relevant articles met the following inclusion criteria: English language, humans undergoing orthopedic surgery, deliberate hypotension used by any method, intraoperative blood loss measured as an outcome, and the trial methodology being randomized and controlled. Four outcomes were analyzed, including estimated blood loss, blood transfused, surgery duration, and quality of the surgical field. For all analyses, the random-effects model was used.Results: Seventeen articles met the inclusion criteria. The surgeries studied included total hip arthroplasty (seven), orthognathic surgery (eight), total knee arthroplasty (one) and spinal fusion (one). A total of 636 patients were randomized across all studies. For blood loss, the overall weighted mean difference favoured treatment, with a savings of about 287 mL of blood [95% confidence interval (CI): -447, -127]. The mean differences also showed a statistically significant benefit for deliberate hypotension in reducing transfusion requirements (-667 mL of blood transfused; 95% CI: -963, -370). Deliberate hypotension was not shown to reduce the duration of surgery (-1.9 min of surgery; 95% CI: -7.2, 3.5) or improve surgical conditions (surgical field quality rating -0.5; 95% CI: -1.1, 0.2). Conclusion:This review provides some support for the use of deliberate hypotension in reducing blood loss and transfusion requirements in orthopedic surgery, but these results are tempered by the small sample sizes and poor methodological quality of published studies.