Discomfort during the period of waiting before elective surgery can be reduced if patients are prepared with a carbohydrate-rich drink, compared with preoperative oral intake of water or overnight fasting. Visual analog scales can provide useful information about preoperative discomfort in elective surgery patients.

Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

CHO may have a beneficial effect on PONV 12-24 h after laparoscopic cholecystectomy.

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A psychological preparation programme was developed for outpatient surgery in children. The purpose of this study was to determine if the programme could increase retrieval of information and reduce anxiety prior to ENT surgery. After ethical committee approval, 160 children and their parents were included. Eighty children (group 1) received conventional verbal information from an ENT nurse, and another 80 children (group 2) received specific information, including role-play, from a nurse anaesthetist at a preadmission visit. Children's and parents' experience of premedication, operation theatre (OR), i.v.-needle insertion and induction of anaesthesia were evaluated from a self-rating questionnaire. The questionnaire included ratings for anxiety and satisfaction with information and care. The results indicate a clear improvement of the preoperative acquisition of knowledge in all age groups. When it comes to alleviation of fear, a positive effect of the preparation programme was noticed, especially among the younger children (< 5 years), while preoperative anxiety overall was a significantly smaller problem among the older children. The effects of the programme were also related to previous experience of anaesthesia and most beneficial among young children with such experience. Overall, the most negative procedure reported by the children was the i.m. injection for premedication (a routine which was abandoned as a result of the study), followed by the insertion of the i.v. -needle. The parents experienced watching their child fall asleep during induction of anaesthesia as most negative, followed by the insertion of the i.v.-needle. Parents also reported more satisfaction and less anxiety after having received specific information and preparation preoperatively. It was concluded that this preoperative preparation programme is useful in all age groups with regard to information, while alleviation of anxiety and fear was seen mainly among the younger children with previous experience of anaesthesia.

AbstractBackgroundBleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.MethodsMEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.ResultsAltogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs. Conclusions and implicationsThe annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.

Abstract Background and aims: Central neuraxial blocks (CNB: epidural, spinal and their combinations) and other spinal pain procedures can cause serious harm to the spinal cord in patients on antihaemostatic drugs or who have other risk-factors for bleeding in the spinal canal. The purpose of this narrative review is to provide a practise advisory on how to reduce risk of spinal cord injury from spinal haematoma (SH) during CNBs and other spinal pain procedures. Scandinavian guidelines from 2010 are part of the background for this practise advisory. Methods: We searched recent guidelines, PubMed (MEDLINE), SCOPUS and EMBASE for new and relevant randomised controlled trials (RCT), case-reports and original articles concerning benefits of neuraxial blocks, risks of SH due to anti-haemostatic drugs, patient-related risk factors, especially renal impairment with delayed excretion of antihaemostatic drugs, and specific risk factors related to the neuraxial pain procedures. Results and recommendations: Epidural and spinal analgesic techniques, as well as their combination provide superior analgesia and reduce the risk of postoperative and obstetric morbidity and mortality. Spinal pain procedure can be highly effective for cancer patients, less so for chronic non-cancer patients. We did not identify any RCT with SH as outcome. We evaluated risks and recommend precautions for SH when patients are treated with antiplatelet, anticoagulant, or fibrinolytic drugs, when patients’ comorbidities may increase risks, and when procedure-specific risk factors are present. Inserting and withdrawing epidural catheters appear to have similar risks for initiating a SH. Invasive neuraxial pain procedures, e.g. spinal cord stimulation, have higher risks of bleeding than traditional neuraxial blocks. We recommend robust monitoring routines and treatment protocol to ensure early diagnosis and effective treatment of SH should this rare but potentially serious complication occur. Conclusions: When neuraxial analgesia is considered for a patient on anti-haemostatic medication, with patient-related, or procedure-related risk factors, the balance of benefits against risks of bleeding is decisive; when CNB are offered exclusively to patients who will have a reduction of postoperative morbidity and mortality, then a higher risk of bleeding may be accepted. Robust routines should ensure appropriate discontinuation of anti-haemostatic drugs and early detection and treatment of SH. Implications: There is an on-going development of drugs for prevention of thromboembolic events following surgery and childbirth. The present practise advisory provides up-to-date knowledge and experts’ experiences so that patients who will greatly benefit from neuraxial pain procedures and have increased risk of bleeding can safely benefit from these procedures. There are always individual factors for the clinician to evaluate and consider. Increasingly it is necessary for the anaesthesia and analgesia provider to collaborate with specialists in haemostasis. Surgeons and obstetricians must be equally well prepared to collaborate for the best outcome for their patients suffering from acute or chronic pain. Optimal pain management is a prerequisite for enhanced recovery after surgery, but there is a multitude of additional concerns, such as early mobilisation, early oral feeding and ileus prevention that surgeons and anaesthesia providers need to optimise for the best outcome and least risk of complications.

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