Postoperative pain trajectory and opioid requirements after laparoscopic bariatric surgery: a single-centre historical cohort study.

PURPOSE: Concerns around delayed emergence and opioid-induced ventilatory impairment in bariatric surgery can lead to intraoperative reliance on short-acting opioids and avoidance of long-acting analgesics with potential sedative effects. Nevertheless, an overly-conservative intraoperative analgesic strategy may result in significant pain at emergence and higher opioid requirements in later phases of care. We sought to establish the pattern of intraoperative analgesic use in bariatric surgical patients as well as their postoperative pain trajectory and opioid requirements. METHODS: We undertook a single-centre historical cohort study. We explored associations between intraoperative analgesic interventions and pain scores and opioid requirements in postanesthesia care units (PACUs), and associations between the quality of analgesia at emergence and subsequent pain and patient-centred recovery outcomes. RESULTS: We extracted perioperative data for 939 patients who underwent bariatric metabolic surgery between January 2018 and October 2019. Only 39% of patients received long-acting opioids intraoperatively and there was minimal use of nonopioid analgesic adjuncts. Nearly 80% of patients reported moderate-to-severe pain on PACU arrival; 97% of patients received intravenous opioids for rescue analgesia (mean dose, 31 mg oral morphine equivalents). Lower pain scores at PACU admission and discharge were associated with subsequent lower inpatient pain scores, lower opioid requirements, shorter time to ambulation, and shorter length of hospital stay. CONCLUSION: In bariatric surgical patients, effective intraoperative analgesic strategies that improve early pain control may have an impact on recovery and pain experience. Judicious use of intraoperative opioids coupled with opioid-sparing multimodal analgesic techniques should be considered and balanced against concerns regarding opioid-related adverse effects in this patient population.

RéSUMé: OBJECTIF: Les préoccupations concernant l'émergence retardée et l'insuffisance ventilatoire induite par les opioïdes en chirurgie bariatrique peuvent conduire à une dépendance peropératoire aux opioïdes à courte durée d'action et à l'évitement des analgésiques à action prolongée ayant des effets sédatifs potentiels. Néanmoins, une stratégie analgésique peropératoire trop conservatrice peut entraîner une douleur importante à l'émergence et des besoins en opioïdes plus élevés dans les phases ultérieures des soins. Nous avons cherché à établir le profil d'utilisation des analgésiques peropératoires chez les patient·es en chirurgie bariatrique ainsi que leur trajectoire de douleur postopératoire et leurs besoins en opioïdes. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique. Nous avons exploré les associations entre les interventions analgésiques peropératoires et les scores de douleur et les besoins en opioïdes dans les salles de réveil, ainsi que les associations entre la qualité de l'analgésie à l'émergence et la douleur ultérieure et les résultats de récupération centrés sur les patient·es. RéSULTATS: Nous avons extrait les données périopératoires de 939 patient·es ayant bénéficié d'une chirurgie métabolique bariatrique entre janvier 2018 et octobre 2019. Seulement 39 % des patient·es ont reçu des opioïdes à action prolongée en peropératoire et l'utilisation d'analgésiques auxiliaires non opioïdes a été minimale. Près de 80 % des patient·es ont signalé une douleur modérée à sévère à leur arrivée en salle de réveil; 97 % des patient·es ont reçu des opioïdes par voie intraveineuse pour une analgésie de secours (dose moyenne, équivalents de morphine orale de 31 mg). Des scores de douleur plus faibles à l'admission et à la sortie de la salle de réveil ont été associés à des scores de douleur plus faibles en milieu hospitalier, à des besoins en opioïdes plus faibles, à un délai avant l'ambulation plus court et à une durée d'hospitalisation plus courte. CONCLUSION: Chez la patientèle de chirurgie bariatrique, des stratégies analgésiques peropératoires efficaces qui améliorent le contrôle précoce de la douleur peuvent avoir un impact sur la récupération et l'expérience de la douleur. L'utilisation judicieuse d'opioïdes peropératoires associée à des techniques analgésiques multimodales d'épargne opioïde doit être envisagée et mise en balance avec les préoccupations concernant les effets indésirables liés aux opioïdes dans cette population de patient·es.

Erector spinae block: beyond the torso.

PURPOSE OF REVIEW: This article aims to summarize the current literature describing the application of erector spinae plane (ESP) blocks for regional anesthesia of upper and lower limbs and to discuss the advantages and limitations. RECENT FINDINGS: Investigations are still at an early stage but results are promising. High thoracic ESP blockade can relieve acute and chronic shoulder pain through local anesthetic diffusion to cervical nerve roots, although it may not be as effective as direct local anesthetic injection around the brachial plexus. It does, however, preserve motor and phrenic nerve function to a greater extent. It will also block the T2 innervation of the axilla which can be a source of pain in complex arthroscopic shoulder surgery. Lumbar ESP blocks provide effective analgesia following hip arthroplasty and arthroscopy, and appear comparable to lumbar plexus, quadratus lumborum, and fascia iliaca blocks. Unlike the latter, they are motor-sparing and are associated with improved postoperative ambulation. SUMMARY: High thoracic and lumbar ESP blocks have the potential to provide adequate analgesia of the upper and lower limbs respectively, without causing significant motor block. They are thus alternative methods of regional anesthesia when other techniques are not feasible or have undesirable adverse effects.

Reinstating a national simulation programme in anaesthesiology during the coronavirus pandemic.

Background: With the introduction of strict public health measures due to the coronavirus pandemic, we have had to change how we deliver simulation training. In order to reinstate the College of Anaesthesiologists Simulation Training (CAST) programme safely, we have had to make significant logistical changes. We discuss the process of reopening a national simulation anaesthesiology programme during a pandemic. Methods: We approached how to reinstate the programme with three distinct but intertwined projects, as in the following: (1) a survey of effects of the pandemic on training opportunities for anaesthesiology trainees, (2) proposals for methods of reinstating simulation were developed under the headings avoidance, compromise, accommodation and collaboration. A small online video-assisted simulation pilot was carried out to test the compromise method, (3) having opted for combined accommodation (onsite with smaller participant numbers and safety measures) and collaboration (with other regional centres), a postreinstatement evaluation during a 4-month period was carried out. Results: (1) Eighty-five per cent of 64 trainees surveyed felt that they had missed out not only just on simulation-based education (43%) but also on other training opportunities, (2) when five trainees were asked to state on a 1 to 5 Likert scale (strongly disagree, disagree, undecided, agree and strongly agree) whether online video-assisted simulation was similar to face-to-face simulation in four categories (realism, immersion, sense of crisis and stress), only 9 (45%) of the 20 answers agreed they were similar, (3) When onsite simulation was reinstated, the majority of trainees felt that training was similar to prepandemic and were happy to continue with this format. Conclusion: In order to reinstate simulation, we have identified that accommodation and collaboration best suited the CAST while compromise failed to rank high among trainees' preferences. Onsite courses will continue to be delivered safely while meeting the high standards our trainees have come to expect.