Anaesthesiology Update

Hull and East Yorkshire Hospitals NHS Trust Anaesthesiology Update

November 2018

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Latest from the Cochrane Database of Systematic Reviews

Pre‐emptive and preventive opioids for postoperative pain in adults undergoing all types of surgery Brett Doleman, Jo Leonardi‐Bee, Thomas P Heinink, Debamita Bhattacharjee, Jon N Lund, John P Williams Abstract - Background Postoperative pain is a common consequence of surgery and can have deleterious effects. It has been suggested that the administration of opioid analgesia before a painful stimulus may improve pain control. This can be done in two ways. We defined 'preventive opioids' as opioids administered before i…

Adverse side effects of dexamethasone in surgical patients Jorinde AW Polderman, Violet Farhang‐Razi, Susan Van Dieren, Peter Kranke, J Hans DeVries, Markus W Hollmann, Benedikt Preckel, Jeroen Hermanides Abstract - Background In the perioperative period, dexamethasone is widely and effectively used for prophylaxis of postoperative nausea and vomiting (PONV), for pain management, and to facilitate early discharge after ambulatory surgery. Long‐term treatment with steroids has many side effects, such as adrenal insufficien…

Laryngeal mask airway versus endotracheal tube for percutaneous dilatational tracheostomy in critically ill adults Reinhard Strametz, Martin N Bergold, Tobias Weberschock Abstract - Background Percutaneous dilatational tracheostomy (PDT) is one of the most common bedside surgical procedures performed in critically ill adults, on intensive care units (ICUs), who require long‐ term ventilation. PDT is associated with relevant life‐threatening complications: Cuff rupture or accidental extubat…

Results from Embase Contents 116 of 116 results on EMBASE - (((0304-3959 OR 0007-0912 OR 1471-6771 OR 1528-1175 OR 0003-3022 OR 1526-5900 OR 1441-2772 OR 1744-8069 OR 0049-0172 OR 1098-7339 OR 1526-7598 OR 0003-2999 OR 0885-3924 OR 0003-2409 OR 1365-2044 OR 1533-3159 OR 1090-3801 OR 0749-8047 OR 1525-1403 OR 1094-7159 OR 0001-5172 OR 1399-6576 OR 0265-0215 OR 1365-2346 OR 1155-5645 OR 1460-9592 OR 1537-1921 OR 0898-4921 OR 0832-610X OR 1496-8975 OR 1526-2375 OR 1526-4637 OR 0375-9393 OR 1178-7090 OR 1203-6765 OR 0959-289X OR 1753-3740 OR 1521-6896 OR 1473-6500 OR 0952-7907 OR 2090-1542 OR 2090-1550 OR 1387-1307 OR 1573-2614 OR 1530-7085 OR 1533-2500 OR 1471-2253 OR 1532-8422 OR 1053-0770 OR 1064-6655 OR 1534-3081 OR 1531-3433 OR 0913-8668 OR 1438-8359 OR 1687-6970 OR 1687-6962 OR 0310-057X OR 1448-0271 OR 1089-2532 OR 1754-9493 OR 0360-1293 OR 0952-8180 OR 1932-2275 OR 0970-9185 OR 0974-5181 OR 0971-9784 OR 1551-7489).is AND ((Sevoflurane AND agitation).ti,ab OR *"RESPIRATION CONTROL"/ OR *"AIRWAY OBSTRUCTION"/ OR *"AIRWAY REMODELING"/ OR *"AIRWAY RESISTANCE"/ OR *EXTUBATION/ OR *"DIABETES MELLITUS"/ OR *GYNECOLOGY/ OR *"RESPIRATORY DISTRESS SYNDROME, ADULT"/ OR *"LARYNGEAL MASK"/ OR *"NERVE BLOCK"/ OR *HEART/ OR *"VISCERAL PAIN"/ OR *SEPSIS/ OR *"VASCULAR SURGERY"/ OR *"EXERCISE TEST"/ OR *"HEART FUNCTION TEST"/ OR *DELIRIUM/ OR *"ANTIINFECTIVE AGENT"/ OR *"LOW BACK PAIN"/ OR ("enhanced recovery after surgery" OR ERAS).ti,ab OR *FIBROMYALGIA/ OR *"QUALITY CONTROL PROCEDURES"/ OR *"QUALITY OF LIFE"/ OR ("fluid management").ti,ab)) NOT ("Conference Proceeding" OR Editorial OR Erratum OR Letter OR Note OR "Short Survey").pt) [Since 01- Nov-2018]

1. Radiofrequency denervation improves health-related quality of life in patients with thoracic zygapophyseal joint pain

2. Age-related patterns in cancer pain and its psychosocial impact: Investigating the role of variability in physical and mental health quality of life

3. Physical activity and sleep in chronic fatigue syndrome and fibromyalgia syndrome: Associations with symptom severity in the general population cohort lifelines

4. Clinical Manifestation of Acute, Subacute, and Chronic Low Back Pain in Different Age Groups: Low Back Pain in 35,446 Patients

5. The DIgnity In Advanced DEMentia (DIADEM) Study: Quality of Life of Home Dwelling Patients and Caregiver Burden

6. Clozapine Use in Delirium

7. A Critical Investigation of the Outcomes of Specialist Palliative Day Services on Specific Components of Attendee Quality Of Life: A Mixed Methods Study 8. Delirium in Patients Hospitalized at a Palliative Care Oncology Unit and at a Cardiology Unit in Medellin, Colombia

9. Examining the Effects of Palliative Telehealth Connecting Hospital to Home (Patch) Program on Quality of Life

10. Content Validation and Acceptability of the McGill Quality of Life Questionnaire in Patients Living with Heart Failure

11. A Multidimensional Strategy to Improve Quality of Life in Patients with Multiple Symptoms and Palliative Care Needs: the Development of the MuSt-PC

12. Relational Dimensions of Quality of Life in Inpatient Palliative Facilities

13. Survival and QOL Outcomes with Quality Palliative QUAD SHOT Radiotherapy in Advanced Head and Neck Cancer (HNC) - An Alternative Regimen in Low Resource Countries

14. Caring for a Child with a Complex Chronic Condition: Parent-Reported Burden and Quality of Life

15. Exploratory Study Examining A Composite Index Measuring Sarcopenia and Anxiety in COPD - Relationship with Frailty, Disease Severity, Exertional Dyspnea and Quality of Life

16. A Retrospective Medical Chart Review to Identify Predictive Factors for Terminal Refractory Delirium in Palliative Patients at the End of Life

17. Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain

18. DNA demethylation of P2X7 receptors in spinal astrocytes contributes to visceral pain induced by neonatal colonic inflammation in rats

19. Alteration of resting-state networks in patients with fibromyalgia, complex regional pain syndrome, and other functional somatic pain syndrome

20. Emotional Influences on Cognitive Processing in Fibromyalgia Patients with Different Depression Levels

21. A comparison of the incidence of supraventricular arrhythmias between thoracic paravertebral and intercostal nerve blocks in patients undergoing thoracoscopic surgery A randomised trial

22. Effect of Intravenous Oxycodone in Combination with Different Doses of Dexmedetomdine on Sleep Quality and Visceral Pain in Patients after Abdominal Surgery

23. Clinical significance and prognosis of serum tenascin-C in patients with sepsis 11 Medical and Health Sciences 1103 Clinical Sciences 24. Efficacy and safety of dexmedetomidine in peripheral nerve blocks: A meta-analysis and trial sequential analysis

26. Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial

27. Enhanced Recovery After Surgery for Cardiac Surgery: Will We Have the Techniques Needed to Reduce Opioid Use and Still Provide Appropriate Analgesia?

28. Postoperative thoracic and low back pain following endovascular aortic repair associated with stenting location

29. Risk Factors and Outcomes Associated With Sepsis After Coronary Artery Bypass and Open Heart Valve Surgeries

30. Clinical characteristics and prognosis of serous body cavity effusions in patients with sepsis: A retrospective observational study 11 Medical and Health Sciences 1103 Clinical Sciences

31. Dying as a pathway to death in sepsis

32. Airway management practice in adults with an unstable cervical spine: The harborview medical center experience

33. Readiness for discharge after foot and ankle surgery using peripheral nerve blocks: A randomized controlled trial comparing spinal and general anesthesia as supplements to nerve blocks

34. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial

35. Slow waves, cognitive disintegration, and delirium

36. Enhanced Recovery After Surgery: Are the Principles Applicable to Adult and Geriatric Acute Care and Trauma Surgery?

37. Fibreoptic-guided tracheal intubation through i-gel and LMA Protector^TM supraglottic airway devices - a randomised comparison

38. Micro-fragmented fat injection reduces sepsis-induced acute inflammatory response in a mouse model 39. Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: A randomized controlled trial

40. Airway management research: a systematic review

41. Co-administration of dexamethasone with peripheral nerve block: intravenous vs perineural application: systematic review, meta-analysis, meta-regression and trial- sequential analysis

42. Local anaesthetic dosage of peripheral nerve blocks in children: analysis of 40 121 blocks from the Pediatric Regional Anesthesia Network database

43. Could patient-controlled thirst-driven fluid administration lead to more rapid rehydration than clinician-directed fluid management? An early feasibility study

45. Current concepts of fluid management in enhanced recovery pathways

46. Perioperative management of tracheocutaneous fistula closure in children: A review of 96 cases

47. Just the facts the role of diagnostic blocks in lumbar facet interventions

48. Incidence and outcomes of sepsis after cardiac surgery as defined by the Sepsis-3 guidelines

49. Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis

50. Use of the LMA GastroTM Airway, a novel dual channel laryngeal mask airway, for endoscopic retrograde cholangiopancreatography: a report of two cases

51. Retrieval of critically ill adults using extracorporeal membrane oxygenation: the nine- year experience in New South Wales

52. Feasibility of automated titration of vasopressor infusions using a novel closed-loop controller

53. Use of the Bougie Endotracheal Tube Introducer in Unstable Cervical Spine Airway Management?

54. Tranexamic Acid Dosing for Cardiac Surgical Patients With Chronic Renal Dysfunction: A New Dosing Regimen 55. Operant Learning Versus Energy Conservation Activity Pacing Treatments in a Sample of Patients With Fibromyalgia Syndrome: A Pilot Randomized Controlled Trial

56. Three versus five lumbar paravertebral injections for inguinal hernia repair in the elderly: a randomized double-blind clinical trial

57. Cytokine Gene Polymorphisms Associated With Various Domains of Quality of Life in Women With Breast Cancer

58. Effects of Androgen Deprivation Therapy on Pain Perception, Quality of Life, and Depression in Men With Prostate Cancer

59. Which Seems to Be Worst Pain Severity and Quality of Life between Patients with Lateral Hip Pain and Low Back Pain

60. Is abnormal glucose tolerance or diabetes a risk factor for knee, hip, or hand osteoarthritis? A systematic review

61. Deep or awake removal of laryngeal mask airway in children at risk of respiratory adverse events undergoing tonsillectomy-a randomised controlled trial

62. Dexamethasone and postoperative hyperglycemia in diabetics undergoing elective hip or knee arthroplasty: A case control study in 238 patients

63. The Effect of Combination Pharmacotherapy on Low Back Pain

64. IV maintenance fluids at McMaster children's hospital: A survey of physicians

65. ICU delirium, clinical outcomes and cost: Systematic review & meta-analysis

66. Emergency department nurses' knowledge and experience with the new sepsis-3 criteria: A survey

67. The epidemiology of infections and sepsis in the prehospital setting

68. The effect of cerebral perfusion pressure guided therapy on acute respiratory distress syndrome in traumatic brain injury

69. Thoracoscopic and Ultrasound Guidance for Optimization of Medication Spread during Thoracic Paravertebral Nerve Blockade

71. Risk prediction models for delirium in the intensive care unit after cardiac surgery: a systematic review and independent external validation 72. Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length

73. Efficacy of a new dual channel laryngeal mask airway, the LMAGastroTM Airway, for upper gastrointestinal endoscopy: a prospective observational study

74. Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation

76. Is a Retrolaminar Approach to the Thoracic Paravertebral Space Possible?: A Human Cadaveric Study

77. Pericapsular Nerve Group (PENG) Block for Hip Fracture

78. Serratus Plane Block: A Cadaveric Study to Evaluate Optimal Injectate Spread

79. Lipid Emulsion Pretreatment Decreased the Maximum Total and Free Plasma Concentration of Levobupivacaine for Femoral and Sciatic Nerve Block in Below-Knee Fracture Surgery

80. Ultrasound-Guided Selective Versus Conventional Block of the Medial Brachial Cutaneous and the Intercostobrachial Nerves: A Randomized Clinical Trial

81. Mindfulness for Chronic Low Back Pain: A Qualitative Analysis

82. Re: Spinal Cord Stimulation (SCS) with Anatomically Guided (3D) Neural Targeting Shows Superior Chronic Axial Low Back Pain Relief Compared to Traditional SCS-LUMINA Study

83. Guidelines for Composing and Assessing a Paper on the Treatment of Pain: A Practical Application of Evidence-Based Medicine Principles to the Mint Randomized Clinical Trials

84. Sepsis in pregnancy and the puerperium

85. Diabetes Mellitus: Preoperative Concerns and Evaluation

86. Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain

87. Recruitment manoeuvres dislodge mucus towards the distal airways in an experimental model of severe pneumonia

88. Identifying and Engaging Neuronal Oscillations by Transcranial Alternating Current Stimulation in Patients With Chronic Low Back Pain: A Randomized, Crossover, Double-Blind, Sham-Controlled Pilot Study 89. Characteristics Associated With High-Impact Pain in People With Temporomandibular Disorder: A Cross-Sectional Study

90. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study

91. The Relationship of Endocannabinoidome Lipid Mediators With Pain and Psychological Stress in Women With Fibromyalgia: A Case-Control Study

92. Spouse Criticism/Hostility Toward Partners With Chronic Pain: The Role of Spouse Attributions for Patient Control Over Pain Behaviors

94. Does Sensorimotor Incongruence Trigger Pain and Sensory Disturbances in People With Chronic Low Back Pain? A Randomized Cross-Over Experiment

95. Exposure and cognitive-behavioural therapy for chronic back pain: An RCT on treatment processes

97. Is a history of severe episodic low back pain an indicator of a discogenic etiology?

98. Prospective validation of a new airway management algorithm and predictive features of intubation difficulty

99. Effects of thoracic epidural analgesia on exercise-induced myocardial ischaemia in refractory angina pectoris

100. The Impact of Chronic Discogenic Low Back Pain: Costs and Patients' Burden

102. Predictors and outcome of early extubation in infants postcardiac surgery: A single- center observational study

105. Management Strategies for Severe and Refractory Acute Respiratory Distress Syndrome: Where Do We Stand in 2018?

106. Ultrasound guided repositioning of a new suture-method catheter for adductor canal block - A randomized pilot study in healthy volunteers

107. Best perioperative practice in management of ambulatory patients with obstructive sleep apnea

108. Rebound pain after regional anesthesia in the ambulatory patient

110. Alterations in Temporal Summation of Pain and Conditioned Pain Modulation Across an Episode of Experimental Exercise-Induced Low Back Pain

111. Laryngeal mask airway UniqueTM position in paediatric patients undergoing magnetic resonance imaging (MRI): Prospective observational study

113. A retrospective comparison of propofol to dexmedetomidine for pediatric magnetic resonance imaging sedation in patients with mucopolysaccharidosis type II

114. Opioid Induced Hyperalgesia with Intrathecal Infusion of High-Dose Fentanyl

116. The effect of dexmedetomidine on delirium and agitation in patients in intensive care: systematic review and meta-analysis with trial sequential analysis

Full strategy

Results 116 of 116 results on EMBASE - (((0304-3959 OR 0007-0912 OR 1471-6771 OR 1528- 1175 OR 0003-3022 OR 1526-5900 OR 1441-2772 OR 1744-8069 OR 0049-0172 OR 1098- 7339 OR 1526-7598 OR 0003-2999 OR 0885-3924 OR 0003-2409 OR 1365-2044 OR 1533- 3159 OR 1090-3801 OR 0749-8047 OR 1525-1403 OR 1094-7159 OR 0001-5172 OR 1399- 6576 OR 0265-0215 OR 1365-2346 OR 1155-5645 OR 1460-9592 OR 1537-1921 OR 0898- 4921 OR 0832-610X OR 1496-8975 OR 1526-2375 OR 1526-4637 OR 0375-9393 OR 1178- 7090 OR 1203-6765 OR 0959-289X OR 1753-3740 OR 1521-6896 OR 1473-6500 OR 0952- 7907 OR 2090-1542 OR 2090-1550 OR 1387-1307 OR 1573-2614 OR 1530-7085 OR 1533- 2500 OR 1471-2253 OR 1532-8422 OR 1053-0770 OR 1064-6655 OR 1534-3081 OR 1531- 3433 OR 0913-8668 OR 1438-8359 OR 1687-6970 OR 1687-6962 OR 0310-057X OR 1448- 0271 OR 1089-2532 OR 1754-9493 OR 0360-1293 OR 0952-8180 OR 1932-2275 OR 0970- 9185 OR 0974-5181 OR 0971-9784 OR 1551-7489).is AND ((Sevoflurane AND agitation).ti,ab OR *"RESPIRATION CONTROL"/ OR *"AIRWAY OBSTRUCTION"/ OR *"AIRWAY REMODELING"/ OR *"AIRWAY RESISTANCE"/ OR *EXTUBATION/ OR *"DIABETES MELLITUS"/ OR *GYNECOLOGY/ OR *"RESPIRATORY DISTRESS SYNDROME, ADULT"/ OR *"LARYNGEAL MASK"/ OR *"NERVE BLOCK"/ OR *HEART/ OR *"VISCERAL PAIN"/ OR *SEPSIS/ OR *"VASCULAR SURGERY"/ OR *"EXERCISE TEST"/ OR *"HEART FUNCTION TEST"/ OR *DELIRIUM/ OR *"ANTIINFECTIVE AGENT"/ OR *"LOW BACK PAIN"/ OR ("enhanced recovery after surgery" OR ERAS).ti,ab OR *FIBROMYALGIA/ OR *"QUALITY CONTROL PROCEDURES"/ OR *"QUALITY OF LIFE"/ OR ("fluid management").ti,ab)) NOT ("Conference Proceeding" OR Editorial OR Erratum OR Letter OR Note OR "Short Survey").pt) [Since 01-Nov-2018] 1. Radiofrequency denervation improves health-related quality of life in patients with thoracic zygapophyseal joint pain Author(s): Hambraeus J.; Persson J.; Hambraeus K.S. Source: Pain Medicine (United States); May 2018; vol. 19 (no. 5); p. 914-919 Publication Date: May 2018 Publication Type(s): Article Abstract:Objective. To describe a practical approach for the diagnosis and treatment of thoracic zygapophyseal joint pain and to present preliminary clinical data on the effects of this treatment approach on healthrelated quality of life. Design. An observational study. Setting. Specialist outpatient pain clinic in northern Sweden. Subjects. Patients with long- Term thoracic pain. Methods. We describe a method of radiofrequency denervation of thoracic zygapophyseal joints. We compared health-related quality of life between patients who underwent radiofrequency denervation of thoracic zygapophyseal joints and patients who underwent radiofrequency denervation for lumbar and cervical zygapophyseal joint pain. Results. Treatment according to the Spine Intervention Society Guidelines was performed on the lumbar region in 178 patients and in the cervical region in 55 patients. Another 82 patients were treated in the thoracic region with our proposed technique. A survival plot of improvements in health-related quality of life revealed that all three treatments were effective in 65% or more of patients. The improvement in health-related quality of life was maintained for 12 or more months after treatment in 47% to 51% of patients. Conclusions. Our results suggest that radiofrequency denervation of thoracic zygapophyseal joint pain is as effective as radiofrequency denervation, the standard treatment, for lumbar and cervical zygapophyseal joint pain. If these results can be confirmed by other centers, radiofrequency denervation is likely to become more widely available for the treatment of thoracic zygapophyseal joint pain.Copyright © 2018 Oxford University Press. All Rights Reserved. Database: EMBASE

2. Age-related patterns in cancer pain and its psychosocial impact: Investigating the role of variability in physical and mental health quality of life Author(s): Gauthier L.R.; Macpherson A.K.; Shepherd F.A.; Gagliese L.; Dworkin R.H.; Warr D.; Pillai Riddell R.; Rodin G.; Zimmermann C.; Lawrence Librach S.; Moore M. Source: Pain Medicine (United States); Apr 2018; vol. 19 (no. 4); p. 658-676 Publication Date: Apr 2018 Publication Type(s): Article Abstract:Objective. Age-related patterns in cancer pain remain equivocal. Most studies ignore heterogeneity across multiple domains of well-being, and the potential role of physical (PH) and mental health (MH) quality of life (QOL) in these age-related patterns is unknown. We investigated the relationships between age and cancer pain intensity, qualities, and interference, and physical and psychosocial adaptation and the interaction between age and PH and MH QOL on pain and adaptation to cancer pain. Design. In this cross-sectional study, 244 patients with advanced cancer and pain completed measures of pain, QOL, physical function, and psychosocial well-being. Pearson's correlations and ANOVAs assessed relationships between age and demographic and clinical factors, pain, and physical and psychosocial measures. Regression models tested the role of age and its interaction with PH and MH QOL on pain and physical and psychosocial adaptation. Results. Older age was associated with a lower likelihood of receiving an opioid prescription, greater likelihood of having comorbidities, and worse functional status. When we did not account for these factors, age was not associated with pain and most adaptation indices. When we did account for these factors and PH QOL, older age was associated with lower non- neuropathic and neuropathic pain and several indices of psychosocial adaptation. Most interestingly, older age was associated with lower non-neuropathic pain among those with high, but not low, MH QOL. Conclusions. This study addresses knowledge gaps about factors underlying age-related patterns in cancer pain. Impaired MH QOL may be a proxy for age- related patterns in cancer pain. Summary. This study investigated age-related patterns in the experience of cancer pain and the role of quality of life in resilience and vulnerability to pain and adaptation to pain. Older age is associated with lower non-neuropathic pain among those with high, but not low, mental health quality of life, suggesting that impaired mental health quality of life is an important indicator of vulnerability to multidimensional pain outcomes.Copyright © 2018 Oxford University Press. All rights reserved. Database: EMBASE

3. Physical activity and sleep in chronic fatigue syndrome and fibromyalgia syndrome: Associations with symptom severity in the general population cohort lifelines Author(s): Joustra M.L.; Zijlema W.L.; Rosmalen J.G.M.; Janssens K.A.M. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article Available at Pain Research and Management - from Europe PubMed Central - Open Access Available at Pain Research and Management - from Hindawi Open Access Journals Available at Pain Research and Management - from Pubmed Central - Open Access Abstract:Objective. The aim of the current study was to compare physical activity and sleep duration between patients with chronic fatigue syndrome (CFS), patients with fibromyalgia syndrome (FMS), and controls and to examine the association between physical activity level and sleep duration with symptom severity within these patient groups. Methods. This study used data of LifeLines, a general population cohort in which 1.0% (n=943, 63.7% female, age 44.9 (SD 11.6) years) reported CFS, 3.0% (n=2,714; 91.6% female; age 48.4 (SD 10.7) years) reported FMS, and 95.7% (n=87,532; 57.9% female; age 44.3 (SD 12.4) years) reported neither CFS nor FMS. Physical activity, sleep duration, and symptom severity were assessed by questionnaires and analysed using ANCOVA and regression analyses, adjusted for age, sex, body mass index, smoking, and educational level. Results. Patients with CFS and FMS had significantly lower physical activity scores (8834 +/- 5967 and 8813 +/- 5549 MET * minutes) than controls (9541 +/- 5533; p<0.001). Patients with CFS had the longest sleep duration (466 +/- 86 minutes) compared to patients with FMS and controls (450 +/- 67 and 446 +/- 56; p<0.001). A linear association between physical activity, sleep duration, and symptom severity was only found in controls, in whom higher physical total activity scores and longer sleep duration were associated with a lower symptom severity. In contrast, quadratic associations were found in all groups: both relatively low and high physical activity scores and relatively short and long sleep duration were associated with higher symptom severity in CFS, FMS, and controls. Conclusion. This study indicates that patients with CFS or FMS sleep longer and are less physically active than controls on average. Both low and high levels of physical activity and short and long sleep duration are associated with higher symptom severity, suggesting the importance of patient-tailored treatment.Copyright © 2018 Monica L. Joustra et al. Database: EMBASE

4. Clinical Manifestation of Acute, Subacute, and Chronic Low Back Pain in Different Age Groups: Low Back Pain in 35,446 Patients Author(s): Hullemann P.; Gierthmuhlen J.; Forstenpointner J.; Baron R.; Keller T.; Kabelitz M.; Freynhagen R.; Tolle T. Source: Pain Practice; Nov 2018; vol. 18 (no. 8); p. 1011-1023 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29710429 Available at Pain Practice - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Low back pain (LBP) is a major healthcare problem causing tremendous economic costs. Method(s): Clinical manifestation of LBP was characterized in 35,446 patients. We focused on the comparison of the acute, subacute, and chronic LBP stage with regard to patients' ages, based on epidemiologic and clinical questionnaires (eg, painDETECT Questionnaire, Pain Disability Index), pain intensity, pain descriptors, and functional impairment. Result(s): We found that neuropathic components were most frequent in chronic LBP patients at the ages of 51 to 60 years. Elderly LBP patients showed a decrease in neuropathic and an increase in nociceptive pain. The most frequently reported pain descriptors were "pressure pain" and "pain attacks" through all stages of LBP, whereas "burning" and "prickling" were most frequent in the chronic stage. Patients after back surgery presented neuropathic pain symptoms most frequently and had the highest amount of pain medication intake. Conclusion(s): Burning and prickling were revealed as possible indicators for LBP chronicity. Combined with pain attacks and pressure pain, these 4 pain descriptors might be a promising adjunct to pain intensity in terms of outcome parameters for future LBP studies. The decrease of neuropathic pain syndromes in the elderly might be explained by degenerative processes. The presented work provides important insights on LBP management in the acute, subacute, and chronic stages.Copyright © 2018 World Institute of Pain Database: EMBASE

5. The DIgnity In Advanced DEMentia (DIADEM) Study: Quality of Life of Home Dwelling Patients and Caregiver Burden Author(s): Hum A.; Tay R.; Ali N.B.; Wu H.Y.; Leong I.; Chin J.J.; Lee A.; Mervyn koh Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Background: Advanced dementia (AD) patients transition between the home/long term care facility and the hospital whenever there is a crisis, especially towards the end of life (EOL). Coordinated approaches to care in the form of an integrated palliative homecare service may enhance access to support services which would help manage their symptoms at home, thus improving their quality of life (QoL) and alleviating caregiver burden. Objective(s): To study the QoL and symptom burden of AD patients living at home as well as the burden familial caregivers face. Design(s): Prospective analysis of cohort data. Setting(s): Homecare setting, Singapore. Subjects: 357 patients (median age 88 years) at Functional Assessment Staging (FAST) 7 with a recent history of pneumonia, albumin <35g/L and/or enteral feeding were enrolled into the homecare programme. Long term care facility patients were excluded. Method(s): In addition to the Quality of Life in Late-Stage Dementia (QUALID) assessment, other dementia-specific tools [Pain Assessment in Advanced Dementia, Neuropsychiatric Inventory Questionnaire and Mini Nutritional Assessment (MNA)] were used to evaluate patients' symptoms. The Zarit Burden Interview evaluated caregiver burden. Demographic information including their healthcare utilisation before enrolment into the homecare programme was extracted by medical chart reviews. Result(s): The median QUALID score was 23 (IQR 8.0), which correlated with the presence of pain (r = 0.36, P < 0.0001) and behavioural issues (r = 0.36, P < 0.0001). Enteral feeding was associated with a lower QoL [QUALID score of 24 (IQR 8.0)] compared to oral feeding [QUALID score of 21 (IQR 8.0), P = 0.001]. Of the 286 patients, 52.4% suffered pain whilst 81.0% experienced behavioural challenges. Familial caregivers experienced mild-moderate burden with a median ZBI score of 25 (IQR 20.0). Those who did not have domestic help experienced greater burden with a median ZBI score of 38.0 (IQR 24.5). Conclusion(s): Symptoms are prevalent in AD patients which affect their QoL. Patients on enteral feeding have further compromised QoL. Their high care needs affected familial caregivers' burden. An integrated palliative homecare service for AD patients aims to support caregivers in their caregiving journey to improve the quality of care for patients at their EOL, potentially rationalising healthcare utilisation.Copyright © 2018 Database: EMBASE

6. Clozapine Use in Delirium Author(s): Pasniciuc S.; Setla J. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:In palliative care and hospice symptom control remains crucial as patients continue to decline and develop new complications. Among difficult to control symptoms, delirium appears by far the most challenging in the context of patients approaching stages of multiorgan failure and being on therapy including drugs that can induce delirium by themselves and/or through interactions among each other. Patients with Parkinson disease are exquisitely sensitive to psychotropics as most may worsen their baseline symptoms. While quetiapine is commonly used, failure to respond leaves the clinician with extremely limited options. We present the case of a 75 yo gentleman with advanced stage Parkinson and severe delirium controlled at least partially with low doses clozapine. Clozapine is the first atypical antipsychotic drug used, in use from early 70's, and is listed in the Who Model List of Essential Medicines among the most effective and safe medicines needed in a health system. Its use in United States remains extremely limited due to tight regulations including serial cell counts. As of October 2015 all clozapine products are available only through the Clozapine REMS program that includes enrolling both patient and prescriber and a specific online learning module that has to be completed by the prescriber. For hospice and palliative care providers access to clozapine prescribing remains an important tool in their armamentarium in difficult to treat delirium. Moreover, due to its potential in controlling end of life delirium and its unique side effect profile, clozapine appears suitable for use in delirium accompanying other medical entities specifically in end of life care.Copyright © 2018 Database: EMBASE

7. A Critical Investigation of the Outcomes of Specialist Palliative Day Services on Specific Components of Attendee Quality Of Life: A Mixed Methods Study Author(s): Stevens E.; Dewar B.; Rankin J. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Objectives: Specialist Palliative Day Services (SPDS) provide complex interventions to people with advanced illness. However, despite evidence that a range of palliative care services, provided by clinical experts, improve quality of life this has yet to be established in SPDS. The aim of this study was to critically investigate the outcomes SPDS on specific components of attendee quality of life. Method(s): This was a two-phase, convergent mixed methods study. The 20 week quantitative phase utilised the EQ5D-3L, Hospital Anxiety and Depression Scale, Life Attitude Profile-Revised and Rosenberg Self-esteem Scale (n=21) to measure aspects of quality of life. The exploratory qualitative phase employed individual Emotional Touchpoint interviews (n=15) to investigate the lived experience of attending SPDS. Preliminary data were interrogated using SPSS and thematic analysis. Integrated data were analysed using the themes generated from the qualitative data. Result(s): Convergent findings revealed death anxiety was triggered at point of referral and continued for some across the study period. Convergent findings identified that self-esteem and mood were stable and remained within normal parameters, while partially convergent findings established that functional ability and symptoms were moderately affected by illness and did not vary in severity. Partially divergent findings determined meaning in life varied over time and was low in some across the study period. Conclusion(s): SPDS supports normal self- esteem, mood and acceptable levels symptom burden. However, SPDS does not appear to have an impact on meaning in life in all attendees. Consequently, SPDS did not have a positive impact on overall quality of life of all participants. To remedy this SPDS should be provided through a rehabilitative framework which focuses on providing expert palliative care within each domain of quality of life. Research should further explore the components of meaning in life and how SPDS may support the existential wellbeing of all attendees.Copyright © 2018 Database: EMBASE

8. Delirium in Patients Hospitalized at a Palliative Care Oncology Unit and at a Cardiology Unit in Medellin, Colombia Author(s): Manco N.; Canola J.; Franco J.G.; Gonzalez C.P.; Krikorian A.; Vargas J.J.; Arenas L.; Sanchez E.; Norena P.; Escobar M. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Objective: To compare sociodemographic and clinical features of delirium in patients hospitalized at a palliative care oncology unit (PCOU) and at a clinical cardiology unit (CCU) in a tertiary care center in Medellin, Colombia. Method(s): An observational cross-sectional study was conducted. All patients hospitalized in PCOU and CCU for more than 24 hours in a 180-day period were assessed for delirium using DSM V criteria. Study variables were: age, sex, educational level, diagnosis, history of dementia, Karnofsky Index, and Charlston Index. Potential etiologies of delirium were examined. Dementia severity was assessed using the Delirium Rating Scale-revised-98 (DRS-R98). Descriptive and non- parametric statistical tests were used. Result(s): Preliminary results are presented for the first 6-month follow-up. From 692 potential participants, 98 were eligible and 53 entered the study (29 CCU, 24 PCOU). Delirium prevalence was 6,8% in CCU (n=425) and 10,8% in PCOU (n=222). Patients in the CCU were 8 years older (p<0,02), had a better clinical prognosis (6-month survival estimates of 65.5% vs. 91.7%; p<0,05) and a more frequent history of dementia (51.7% vs. 12.5%; p<0,05). Delirium had multiple etiologies in all cases, more commonly: neoplasia (95.8%), organ failure (89.7%), substance intoxication (66.7%), and infection (50%). Motor types of delirium were: mixed (CCU: 75.9%, PCOU: 50%), hypoactive (CCU: 20.7%, PCOU: 41.7%) and hyperactive (CCU: 3.4%, PCOU: 8.3%). No differences were found between delirium severity and clinical features. Conclusion(s): Delirium is a common condition in patients hospitalized in the CCU and PCOU. Clinical features and severity were found to be similar in both populations. These findings have important clinical implications regarding assessment and therapeutic strategies in inpatients. A larger sample is recommended to confirm results. Future research should focus on pharmacological schemes and corresponding responses.Copyright © 2018 Database: EMBASE

9. Examining the Effects of Palliative Telehealth Connecting Hospital to Home (Patch) Program on Quality of Life Author(s): Costantino R.; Rothwell C.; Groninger H.; Kearney C.; Walker K.; Gressler L. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Objective: The collaboration between palliative care, home health, and telehealth can be used to provide effective, efficient palliative care (PC) outside the walls of the hospital. The Palliative Telehealth Connecting Hospital to Home (PATCH) Program aims to improve patient/provider communication, facilitate a comprehensive approach to medication management, and enhance patient self-care education in a target population of urban-dwelling advanced heart failure patients receiving PC after hospitalization. We examined the quality of life (QOL) of patients before and after enrolling in PATCH. Method(s): Hospitalized patients were approached for consent if the attending physician ordered a PC consultation. Once consented, patients received PC team follow-up meetings (via video conference or phone call) and self reported quality of life using the SF-12v2. Quality of life measurements were collected at baseline and at 60 days post enrollment. From the responses, the following percentages were calculated: patients reporting fair/poor health, less functional limitations due to health, less functional limitations due to emotional problems, and less interference of pain. Result(s): Seventy-one baseline and twenty-six 60- day measurements were collected. 75% of patients reported fair/poor health at baseline compared to 62% post intervention. 96% of patients reported functional limitations due to health at baseline compared to 85% post intervention. 99% of patients reported functional limitations due to emotional problems at baseline compared to 27% post intervention. 62% of patients reported pain interfering quite a bit/extremely compared to 32% post intervention. Discussion(s): PC telehealth is associated with improved QOL as measured by SF-12v2. Fewer patients reported fair/poor health, limitations due to health or emotional problems, and less interference of pain after enrolling PATCH2 as compared to baseline.Copyright © 2018 Database: EMBASE

10. Content Validation and Acceptability of the McGill Quality of Life Questionnaire in Patients Living with Heart Failure Author(s): Laforest E.M.; Michel C.M.; Sheppard R.; Cohen S.R.; Yumnu E. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Objectives: Heart failure (HF) is a progressive and incapacitating disease associated with significant symptom burden and distress. While many disease specific tools exist to measure quality of life (QOL) in HF, none explore existential concerns. The McGill Quality of Life Questionnaire (MQOL) has 17 items, and has the advantages of brevity and an existential sub-scale. The purpose of this study was to assess its content validity and acceptability for the HF population. Method(s): A descriptive cross-sectional survey design was used. A convenience sample of 38 participants, from outpatient and inpatient cardiology departments, was recruited to complete the MQOL and a demographic questionnaire. For each MQOL item, participants were asked to rate its acceptability, clarity, and importance to their QOL. Data analysis included descriptive statistics and the content validity index (CVI): a rating of item relevance on a 0 to 1 scale (a higher number indicating more relevance). Result(s): Study participants were 64% male, and 60% had New York Heart Association (NYHA) class II symptoms. Average self-administered completion time was 16.8 minutes. MQOL items were rated clear by over 90%, and not upsetting by over 97% of participants. 90% of participants found the MQOL a good length. The median importance score for every item was at least 4 (very important) on a scale of one to five. Overall CVI was 0.774, and four of six questions of the existential sub-scale were rated above the cut-off of 0.78. Participants had a few suggestions for additional items such as rating sexual satisfaction and attitudes towards physical limitations. Conclusion(s): Findings suggest that MQOL is acceptable and has good content validity for measuring QOL in HF. However, further research exploring the use of holistic QOL measures in clinical HF care with larger sample sizes and more diverse HF populations are needed.Copyright © 2018 Database: EMBASE

11. A Multidimensional Strategy to Improve Quality of Life in Patients with Multiple Symptoms and Palliative Care Needs: the Development of the MuSt-PC Author(s): de Heij A.; Reyners A.; van der Stap L.; van der Linden Y.; van der Heide A.; Engels Y.; Fransen H.; Janssen D.; Teunissen S.; van Weert H.; van Linde M. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Background: Patients with an advanced illness often experience multiple symptoms in different dimensions (physical, social, psychological, spiritual). Simultaneously occurring symptoms may interact, with additive effects on quality of life. Whereas palliative care guidelines usually focus on single symptoms, it is likely that management of multiple symptoms is often not integrated and can be improved. Objective(s): To improve quality of life in patients with life-limiting diseases, by developing a tool that improves timely and adequate assessment and treatment of simultaneously occurring symptoms. Method(s): In phase 1 the MuSt-PC is developed, a tool that integrates multidimensional screening and management of symptoms. First, we perform a systematic review to identify strategies for multidimensional assessment and management of simultaneously occurring symptoms. Second, a nationwide cross-sectional study is conducted to identify common combinations of symptoms in patients with advanced illness. Third, input from focus groups will provide insight in barriers and facilitators for successful implementation of the tool. Fourth, a RAND Delphi study is performed to develop consensus-based management strategies for combinations of symptoms. In phase 2, the effectiveness of the MuSt-PC is tested in a prospective stepped-wedge trial. The tool is further refined and disseminated in phase 3. Result(s): This project results in the MuSt-PC, including treatment strategies for common combinations of multiple symptoms. Moreover, it provides insight into the feasibility and effectiveness of the MuSt-PC, with quality of life as the primary endpoint. When the tool is effective we will disseminate the MuSt-PC nationwide and internationally, in a form that can be integrated in electronic medical records. Conclusion(s): This national project runs from 2017 to 2020 and delivers valuable information on the occurrence of multidimensional symptoms and a strategy to manage these symptoms. If successful, it will improve the quality of life of patients with an advanced illness.Copyright © 2018 Database: EMBASE

12. Relational Dimensions of Quality of Life in Inpatient Palliative Facilities Author(s): Bulk L.Y.; Bates J.; Nimmon L.; Kimel G.; King N. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Objectives: Dying offers opportunities for growth, reconciliation, and closure of relationships. Supporting relational and social dimensions of health is vital to whole person care. However, the role of relationships in shaping patients' and loved ones' experiences of quality of life following admittance to an inpatient end-of-life care facility is not well understood. The objective of this research and presentation is to enrich understandings about the relational dimensions of care in an inpatient end-of-life care setting, and how relationships impact patients' and loved ones' experiences. Method(s): Two research questions guide this study: 'How do relationships shape a patient's quality of life when facing end of life in care? From the patient's perspective, what do they describe to be their most meaningful relationships? This study is framed by an understanding that meaning resides not in individual minds, but is negotiated between people in and through social interaction and engagement in activities. Data collection involves in-depth interviews with patients and individuals identified as central in their care network (health professionals, family, friends, etc). Pictor charts, a unique visual method used with vulnerable populations, are also created with patients and informal caregivers. These charts are graphical representations of the patients' social worlds, and are used to guide discussion around experiences of roles and relationships. Result(s): Participants richly describe factors impacting the ways they make meaning around their relationships at end of life. These include fluctuating and non-linear understandings of time, meaningful activity taking new shape at the end of life, increased importance placed on reflection around shared experiences, support in the form of 'just being together,' and shifting roles and identities. Conclusion(s): Insights from this study's participants' perspectives will help healthcare professionals, staff, and volunteers support the relational dimensions of experience that foster quality of life at end of life.Copyright © 2018 Database: EMBASE

13. Survival and QOL Outcomes with Quality Palliative QUAD SHOT Radiotherapy in Advanced Head and Neck Cancer (HNC) - An Alternative Regimen in Low Resource Countries Author(s): Kanodia R.; Kumar R.; Bhasker S.; Biswas A.; Verma H.; Pandey R.M.; Chander S. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Introduction: HNC is a major cancer burden in developing countries, especially in Southeast Asia, with nearly two-third presenting in advanced stages having dismal prognosis. We present a prospective study on palliative QUAD SHOT radiotherapy (RT) in advanced HNC patients. Objective(s): To evaluate symptom relief, tumor response, survival and quality of life (QOL) in advanced HNC patients treated with QUAD-SHOT Radiotherapy. Method(s): Among 36 patients, stage IV-A and IV-B comprised 16 and 20 patients respectively. Palliative QUAD SHOT RT delivers 14 Gy in 4 fractions twice daily 6 hours apart on 2 consecutive days. The regimen was designed till 3 cycles given every 4 weekly if tumor did not progress. QOL was assessed with EORTC QLQ-C30 questionnaire. Result(s): Median age of the group was 58 yrs with ECOG PS 2. Most common sites were oral cavity (66.6%), oropharynx (19.5%) and larynx (13.9%). Mean duration of symptoms was 7.5 months with pain (100%), dysphagia (83.3%) and neck swelling (75%) being major symptoms. 23 patients (63.9%) received >=2 cycles of QUAD SHOT RT of which 14 patients (38.9%) completed three cycles. At 1 month post first cycle of QUAD SHOT RT, 23 patients had partial response while one patient each had stable and progressive disease. None had >= grade 2 dermatitis and mucositis. Mean PFS who received >= 2 cycles of QUAD SHOT RT was 5.5 months. The mean global health score (GHS) in this study at the baseline was 45.13 (SD, 13.99), while at 3 and 6 months, the mean score was 63.72 (SD, 11) and 60.41 (SD, 8.65) respectively. Conclusion(s): Palliative QUAD SHOT RT is good alternative option in advanced HNC patients. It produces quick symptomatic relief in short duration of treatment with minimal side effects and improves QOL, thus can be employed effectively in areas with high patient burden in limited resource countries. Keywords: Radiotherapy; Quad shot; Palliation; Advanced head and neck cancer; Supportive careCopyright © 2018 Database: EMBASE

14. Caring for a Child with a Complex Chronic Condition: Parent-Reported Burden and Quality of Life Author(s): Postier A.; Kolste A.; Watson D.; Braaten N.; Catrine K.; Friedrichsdorf S.; Schulz C. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Objectives: Parents caring for children with complex chronic conditions (CCC) face higher care-giving responsibilities, which may negatively impact caregiver burden and quality of life (QOL). The primary goal of this analysis was to measure burden of illness/QOL for parents caring for a child with CCC, and to examine their association with sociodemographic characteristics. Method(s): A survey was delivered to parents of 1,523 children (with and without CCCs) identified through a Midwestern US Medicaid insurance (low income health assistance program) claims database if they received >=1 clinic/hospital visit in 2015. The survey included the CarerQOL scale, questions about disease status, functional limitations, indirect cost indicators (e.g., reduced work) and parent/household characteristics. Result(s): Parents of 280 children (18%) participated. Factors associated with higher caregiver burden scores were: having a child with a progressive or variable disease, functional limitations (e.g., having difficulty eating or drinking), special education needs, and being considered disabled by the state government. Being on work leave, white race, and experiencing major household changes were also associated with higher burden while black race (child/parent) was associated with lower burden. Factors associated with lower QOL were in line with higher burden scores, as was having more education. Higher QOL was associated with black race (child/parent) and Hispanic or Somali ethnicity (child/parent). Compared to parents in the healthy child group, parents of children with CCCs reported more financial difficulty and problems managing care-giving tasks. QOL scores were lower in parents of children with CCCs, but they felt supported. Conclusion(s): Caring for a child with a CCC was associated with higher caregiver burden, lower QOL, and higher indirect costs. Future research is needed to help understand how interdisciplinary health providers can help identify and reduce burden, and improve QOL for patients and their families.Copyright © 2018 Database: EMBASE

15. Exploratory Study Examining A Composite Index Measuring Sarcopenia and Anxiety in COPD - Relationship with Frailty, Disease Severity, Exertional Dyspnea and Quality of Life Author(s): Neo H.-Y.; Xu H. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Background: Recent models of palliative care for COPD shifted from care-provision at the end of life, to emphasizing early integration when symptom burden significantly impairs quality of life (QOL). Sarcopenia was recently shown to associate with reduced exercise capacity, functional performance and health status. Similarly, anxiety is related with poorer QOL, more exacerbations, more re-hospitalizations, prolonged length of stay and higher mortality in COPD. Objective(s): We hypothesize that a bi-dimensional index comprising measurement of sarcopenia and anxiety - SARA score, can identify frailer patients with high symptom burden and significantly diminished QoL, for early palliative care. Method(s): A feasibility study comprising 33 subjects with stage 2-4 COPD are recruited. The SARA scale comprises the SARC-F questionnaire that measures sarcopenia, as well as the anxiety domain of the Hospital Anxiety and Depression Scale (HADS). A composite score derived from the two indices forms the SARA score that ranges 2-6 points. Correlational analyses examined relationships between SARA and markers of frailty (Fried Index, FRAIL questionnaire), exertional dyspnea (eMRCD scale), QoL (Chronic Respiratory Questionnaire, CRQ) and disease severity (CAT score). Univariate analyses were employed to compare the mean score of the above variables between 2 groups (SARA 3 vs SARA <3). Result(s): Subjects had a mean age of 70. 25 (75.8%) have stage 3 and 4 COPD. SARA score demonstrates moderate correlation with eMRCD, CAT, FRAIL and Fried scores, as well as the fatigue, emotional function and mastery domain of the CRQ (all p<0.05). Additionally, it highly correlated with the depression domain of HADS (HADS-D) (p<0.001). Univariate analyses demonstrate that SARA 3 is significantly associated with greater eMRCD, CAT score, FRAIL, Fried's index, HADS-D and the three domain of CRQ listed above. Conclusion(s): Preliminary analysis suggest that the SARA may help identify subjects with greater frailty, more severe disease, higher psychological morbidity and poorer QoL, for early palliative multi-disciplinary interventions. Patients with Chronic Obstructive Pulmonary Disease (COPD) are recurrently hospitalised for exacerbations, during which they frequently suffer significant deconditioning and are discharged home with diminished capacities for self-care. This leads to a vicious cycle of repeated unplanned re-admissions, incremental functional incapacitation, progressive social isolation and mounting psychosocial distress.Copyright © 2018 Database: EMBASE

16. A Retrospective Medical Chart Review to Identify Predictive Factors for Terminal Refractory Delirium in Palliative Patients at the End of Life Author(s): Musa L.; Alexiadis A.; Avitan R.; Tan L. Source: Journal of Pain and Symptom Management; Dec 2018; vol. 56 (no. 6) Publication Date: Dec 2018 Publication Type(s): Conference Abstract Abstract:Within palliative and hospice settings, terminal refractory delirium (TRD) presents particular challenges for clinicians, patients and families. TRD is a diagnosis typically made within the final 24 to 48 hours of life and is highly prevalent, with studies indicating that as many as 88% of patients experience the condition. TRD is characterized by extreme agitation, distress and anxiety that are resistant to standard treatments. The challenging constellation of symptoms that constitute TRD impede communication and interaction at the end of life, which has a profound adverse impact on quality of death, and the psychological wellbeing of the patient, family, and healthcare team. The purpose of this study is to identify a diagnostic criterion predictive for TRD in a tertiary palliative unit through a retrospective chart review for patients who passed away on the unit within a one- year period. Data was extracted from a total of 116 charts, with 44.8% (52/116) showing symptoms of TRD. The regular use of opioids was the only statistically significant variable (p<0.01) predictive of TRD; the odds of TRD developing in patients who regularly use opioids is 4.94 (95% 1.73, 16.7) compared to patients who did not. This study, to our knowledge, is the first study to be done in a Canadian-setting, as previous studies were primarily done in Japanese in-patient oncology settings. This study has highlighted the capricious nature of TRD and the need to better support hospice and palliative clinicians in their capacity to ensure a good death.Copyright © 2018 Database: EMBASE

17. Examining Injustice Appraisals in a Racially Diverse Sample of Individuals With Chronic Low Back Pain Author(s): Trost Z.; Goodin B.; Sturgeon J.; Guck A.; Ziadni M.; Nowlin L.; Scott W. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Injustice perception has emerged as a risk factor for problematic musculoskeletal pain outcomes. Despite the prevalence and impact of chronic low back pain (CLBP), no study has addressed injustice appraisals specifically among individuals with CLBP. In addition, despite racial/ethnic disparities in pain, existing injustice research has relied almost exclusively on white/Caucasian participant samples. The current study examined the associations between perceived injustice and pain, disability, and depression in a diverse community sample of individuals with CLBP (N = 137) -51 (37.2%) white, 43 (31.4%) Hispanic, 43 (31.4%) black or African American). Anger variables were tested as potential mediators of these relationships. Controlling for demographic and pain-related covariates, perceived injustice accounted for unique variance in self-reported depression and disability outcomes, but not pain intensity. State and trait anger, and anger inhibition mediated the association between perceived injustice and depression; no additional mediation by anger was observed. Significant racial differences were also noted. Compared with white and Hispanic participants, black participants reported higher levels of perceived injustice related to CLBP, as well as higher depression and pain-related disability. Black participants also reported higher pain intensity than white participants. Current findings provide initial evidence regarding the role of injustice perception specifically in the context of CLBP and within a racially diverse participant sample. Results highlight the need for greater diversity within injustice and CLBP research as well as research regarding socially informed antecedents of injustice appraisals. Perspective(s): Perceived injustice predicted worse outcomes in CLBP, with effects partially mediated by anger. Black participants reported worse pain outcomes and higher injustice perception than their white or Hispanic counterparts. Given racial inequities within broader health and pain-specific outcomes, this topic is critical for CLBP and perceived injustice research.Copyright © 2018 Database: EMBASE

18. DNA demethylation of P2X7 receptors in spinal astrocytes contributes to visceral pain induced by neonatal colonic inflammation in rats Author(s): Zhang P.-A.; Li M.; Liu X.-L.; Wu R.; Xue L.; Xu G.-Y.; Weng R.-X.; Hu C.-Y. Source: Molecular Pain; 2018; vol. 14 ; p. 18 Publication Date: 2018 Publication Type(s): Conference Abstract Available at Molecular Pain - from Europe PubMed Central - Open Access Available at Molecular Pain - from Pubmed Central - Open Access Available at Molecular Pain - from Unpaywall Abstract:Objective: Irritable bowel syndrome (IBS) is one of the most common gastrointestinal disorders. It is characterized by abdominal pain in conjunction with altered bowel habits. IBS rat model was well established by neonatal colonic inflammation (NCI). However, the pathophysiology of the syndrome remains largely unknown. The aim of the present study is to explore whether and how the epigenetic mechanisms of P2X7 receptors (P2X7R) in the spinal cord contributes to the visceral hypersensitivity induced by NCI. Method(s): Visceral hypersensitivity was identified by colorectal distention (CRD). Methylation-specific PCR and bisulfite sequencing PCR were used to detect the methylation/demethylation status of p2x7r promoter. The binding of transcription factors to p2x7r promoter was measured by chromatin immunoprecipitation assay and Luciferase reporter gene assay in vitro. Result(s): (1) Fluorocitrate treatment significantly reduced the CRD threshold in NCI rats. (2) P2X7Rs in the astrocytes were upregulated in spinal dorsal horn of NCI rats, and its antagonist A438079 markedly increased the CRD threshold and inhibited the activation of astrocytes. (3) NCI obviously demethylated p2x7r CpG island. (4) TET2, TET3, and GATA1 were remarkably upregulated, while MBD2 and MBD4 were significantly downregulated in spinal dorsal horn of NCI rats. (5) The binding of GATA1 with p2x7r promoter was dramatically enhanced in NCI rats. However, MBD4 competitively combined to p2x7r promoter with GATA1 in vitro. (6) TRAF6 level in the astrocytes was greatly increased in the spinal dorsal horn of NCI rats. (7) Knockdown of TRAF6 enhanced the CRD threshold and also led to a significant downregulation of TET3, GATA1, and P2X7Rs. (8) Fluorocitrate or A438079 incubation significantly reduced the spontaneous excitatory postsynaptic current (sEPSC) frequency of neurons in the spinal dorsal horn of NCI rats. Conclusion(s): Epigenetic regulations by TET3 and MBD4 of P2X7R expression in the spinal dorsal horn were involved in adult visceral hyperalgesia in rats with NCI. Activation of TRAF6 upregulated TET3 and GATA1 expression in the astrocytes of spinal dorsal horn of NCI rats. Database: EMBASE

19. Alteration of resting-state networks in patients with fibromyalgia, complex regional pain syndrome, and other functional somatic pain syndrome Author(s): Shibata M.; Kan S.; Watanabe Y.; Tanaka H. Source: Molecular Pain; 2018; vol. 14 ; p. 13 Publication Date: 2018 Publication Type(s): Conference Abstract Available at Molecular Pain - from Europe PubMed Central - Open Access Available at Molecular Pain - from Pubmed Central - Open Access Available at Molecular Pain - from Unpaywall Abstract:The aim of this study was to investigate the alterations of spontaneous brain activity in patients with fibromyalgia (FM), complex regional pain syndrome (CRPS), and other functional somatic syndrome (FSS) with pain. A total of 105 subjects participated in this study (FM 16 cases, CRPS 19 cases, FSS 19 cases, and healthy controls 51 cases). They underwent a 5-min resting-state functional magnetic resonance imaging scan. We performed seed-based correlation analysis. Seed regions were the thalamus, hippocampus, amygdala, nucleus accumbens, default mode network (medial prefrontal cortex, posterior cingulate cortex), salience network (anterior cingulate cortex, anterior insula), dorsal attention network (frontal eye fields and intraparietal sulcus), fronto-parietal network (lateral prefrontal cortex [LPFC], posterior parietal cortex [PPC]). We also performed amplitude of low frequency fluctuations (ALFF)/functional ALFF analysis. We will show the differences and similarities of alterations of spontaneous brain activity among these three categories of pain syndrome and discuss about their pathophysiological mechanisms in the brain. Database: EMBASE

20. Emotional Influences on Cognitive Processing in Fibromyalgia Patients with Different Depression Levels Author(s): Sitges C.; Gonzalez-Roldan A.M.; Montoya P.; Duschek S. Source: Clinical Journal of Pain; Dec 2018; vol. 34 (no. 12); p. 1106-1113 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 29975206 Abstract:Objectives: Comorbid symptoms in fibromyalgia (FM) syndrome, such as mood disorders and cognitive dysfunction, may lead to greater functional impairment than pain itself. This study aimed to unravel the modulating role of depression in response execution and inhibition in FM using an emotional go/no-go task. Material(s) and Method(s): In total, 17 FM patients with low depression, 18 FM patients with high depression, and 18 pain-free controls were included. Pain, happy, and neutral faces were pseudorandomly presented, and participants were asked to respond to male faces (go trials) by pressing a button, and to inhibit their responses if female faces were presented (no-go trials). Result(s): FM patients with high depression showed lower positive affect scores, higher negative affect and pain vigilance scores, and slower reaction times, than FM patients with low depression and pain- free controls. Both subgroups of FM patients also rated pain faces as more arousing than pain-free controls. The lack of group differences in our electrophysiological data, neither in N200 nor in P300 amplitudes, seems to indicate that there was no significant impairment in response execution in response inhibition due to pain. Discussion(s): Taken together, these results add evidence to the notion that depression is associated with higher affective dysregulation and deficit of information-processing speed in FM. Furthermore, our data suggest that pain induces a bias to pain-related information, but the absence of significant group differences in event-related potential amplitudes, calculated with analyses of covariance (ANCOVA) (with pain intensity), seem to show that pain intensity is not a predictor for cognitive dysfunctions. ©Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

21. A comparison of the incidence of supraventricular arrhythmias between thoracic paravertebral and intercostal nerve blocks in patients undergoing thoracoscopic surgery A randomised trial Author(s): Wu C.; Ma W.; Cen Q.; Cai Q.; Wang J.; Cao Y. Source: European Journal of Anaesthesiology; 2018; vol. 35 (no. 10); p. 792-798 Publication Date: 2018 Publication Type(s): Article Abstract:BACKGROUND Postoperative supraventricular arrhythmias are common in patients after thoracoscopic lobectomy. Inadequate pain control has long been recognised as a significant risk factor for arrhythmias. The performance of ultrasound-guided (USG) thoracic paravertebral block (PVB) is increasing as an ideal technique for postoperative analgesia. OBJECTIVE We conducted this study to evaluate whether a single-shot USG thoracic PVB would result in fewer postoperative supraventricular tachycardias (SVT) than intercostal nerve blocks (ICNBs) after thoracoscopic pulmonary resection. DESIGN A randomised controlled study. SETTING A single university hospital. PATIENTS Sixty-eight patients undergoing thoracoscopic lobectomy were randomised into two equal groups of 34. INTERVENTIONS For postoperative pain control, all patients received a total of 0.3 ml kg-1 of a mixture containing 0.5% ropivacaine and 1/200000 epinephrine after placement of needles for either a single thoracic PVB or two individual ICNBs, both guided by ultrasound. Data were obtained during the first 48 postoperative hours. MAIN OUTCOME MEASURES The primary outcome was the incidence of SVT after thoracoscopic pulmonary resection. RESULTS During the first 48 postoperative hours, the incidences of SVT and atrial fibrillation were lower in the USG thoracic PVB group (14.7 vs. 46.9%, P=0.004 and 3.0 vs. 18.8%, P=0.037, respectively). The requirement for beta-receptor blockade was more frequent in the ICNBs group than in the PVB group (5.9 vs. 25%, P=0.033). CONCLUSION After placement of the needle using ultrasound guidance, a single-shot thoracic PVB is a well tolerated and effective technique to reduce the incidences of postoperative SVT and atrial fibrillation in patients undergoing thoracoscopic pulmonary resection. TRIAL REGISTRATION http://www.chictr.org/cn/, registration number: ChiCTR-IOR-17010952.Copyright © 2018 European Society of Anaesthesiology. All rights reserved. Database: EMBASE

22. Effect of Intravenous Oxycodone in Combination with Different Doses of Dexmedetomdine on Sleep Quality and Visceral Pain in Patients after Abdominal Surgery Author(s): Jiang Z.; Song Q.; Bao C.; Chen Z.; Zhou G.; Wang H. Source: Clinical Journal of Pain; Dec 2018; vol. 34 (no. 12); p. 1126-1132 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 30134283 Abstract:Objective: Oxycodone or dexmedetomidine (DEX) alone are widely used in clinical practice. The aim of this study was to observe the effect of 2 oxycodone and DEX combinations on postoperative sleep quality. Method(s): This was a prospective and randomized clinical study. A total of 99 patients underwent laparoscopic-Assisted operations on stomach and intestines with general anesthesia were enrolled and randomly divided into 3 groups according to postoperative analgesic protocol (n=33 each). The analgesic protocols were as follows after the surgery. In group C, 0.6 mg/kg oxycodone alone was diluted to 100 mL in 0.9% saline. In group D 1 or D 2, 0.6 mg/kg oxycodone combined with 2.4 mug/kg or 4.8 mug/kg DEX was diluted to 100 mL in 0.9% saline, respectively. The intravenous patient-controlled analgesia device was set up to deliver a continuous infusion of 3 mL/h and a bolus of 1 mL, with a 12-minute lockout interval. The primary outcome was the percentage of stage 2 nonrapid eye movement (stage N2) sleep. Polysomnography was performed the night before operation (PSG-night0), the first (PSG- night1) and second (PSG-night2) nights after surgery. Result(s): A total of 97 patients were included in the final analysis. Compared with group C, N2 sleep were higher in groups D 1 and D 2 on PSG-night1 (54+/-9% and 53+/-10%, respectively) and PSG-night2 (55+/-7% and 56+/-8%, respectively) (P<0.001 for all comparisons). No differences were observed regarding N1 and N2 sleep between groups D 1 and D 2 on PSG-night1 and PSG-night2 (P>0.05). Group C had higher percentage of N1 sleep on PSG-night1 (37+/-5%) and PSG- night2 (33+/-3%) when compared with groups D 1 and D 2 (P<0.001 for the comparisons). Groups D 1 and D 2 required lower rates of rescue analgesia (5% and 4.7%, respectively; P=0.012) and effective pressing times (10.7+/-4.8 times and 9.9+/-2.6 times, respectively; P<0.05) when compared with group C, whereas no statistical significance was found between groups D 1 and D 2. Furthermore, there were no significant difference about resting visual analogue scales at 4, 6, and 12 hours postoperatively between groups D 1 and D 2. In comparison with the other 2 groups, group D 2 had a higher occurrence of postoperative hypotension (24.2%) (P<0.05), though without significant sinus bradycardia. Discussion(s): DEX combined with oxycodone can improve sleep quality and provide good visceral analgesia. However, larger doses of DEX does not further improve sleep but increases the risk of hypotension. ©Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

23. Clinical significance and prognosis of serum tenascin-C in patients with sepsis 11 Medical and Health Sciences 1103 Clinical Sciences Author(s): Yuan W.; Yang X.; Zhou L.; Hanghua Z.; Xu K.; Zhang W. Source: BMC Anesthesiology; Nov 2018; vol. 18 (no. 1) Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30442110 Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Abstract:Background: Tenascin-C is a pro-inflammatory glycoprotein with various biological functions. High expression of tenascin-C is found in inflammation, tissue remodeling, and autoimmune diseases. However, its expression and clinical significance in sepsis remain unclear. This study was designed to investigate the relationship between serum tenascin-C levels and disease severity and prognosis in patients with sepsis. Method(s): A total of 167 patients with sepsis admitted to the ICU were enrolled. Lood samples were collected within 24 h of admission. Serum tenascin-C levels were measured by enzyme-linked immunosorbent assay (ELISA). Follow-up was performed to observe 30-day mortality. Result(s): Serum tenascin-C levels were significantly elevated in patients with sepsis compared with non-sepsis controls (P < 0.001). Serum tenascin-C levels were higher in nonsurvivors (58 cases) who died within 30 days (34.5%) compared to survivors (109 cases) (P < 0.001). In patients with sepsis, serum tenascin-C levels were significantly positively correlated with SOFA scores (P = 0.011), serum creatinine (P = 0.006), C-reactive protein (CRP) (P = 0.001), interleukin-6 (IL-6) (P < 0.001), and tumor necrosis factor alpha (TNF- alpha) (P = 0.026). Logistic multivariate regression models showed that serum tenascin-C levels were independent contributor of 30-day mortality. Kaplan-Meier curves showed that septic patients with high levels of serum tenascin-C (>=56.9 pg/mL) had significantly higher 30-day mortality than those with lower serum tenascin-C (< 56.9 pg/mL) (P < 0.001). Conclusion(s): Elevated serum tenascin-C was found in septic patients and associated with severity and poor prognosis.Copyright © 2018 The Author(s). Database: EMBASE

24. Efficacy and safety of dexmedetomidine in peripheral nerve blocks: A meta-analysis and trial sequential analysis Author(s): Schnabel A.; Weibel S.; Kranke P.; Reichl S.U.; Zahn P.K.; Pogatzki-Zahn E.M.; Meyer-Frieem C.H. Source: European Journal of Anaesthesiology; 2018; vol. 35 (no. 10); p. 745-758 Publication Date: 2018 Publication Type(s): Article Abstract:BACKGROUND The duration of analgesia provided by nerve blocks is limited if local anaesthetics are administered alone. Therefore, several additives, including dexmedetomidine (DEX), have been investigated in order to prolong postoperative analgesia following single-shot regional anaesthesia. OBJECTIVES The aim of this meta- analysis was to assess the efficacy and safety of the addition of perineural DEX to local anaesthetics compared with local anaesthetics alone or local anaesthetics combined with systemic administration of DEX. DESIGN A systematic review of randomised controlled trials (RCT) with meta-analysis, trial sequential analysis and assessment of the quality of evidence by the GRADE approach. DATA SOURCES The databases MEDLINE, CENTRAL and EMBASE (to May 2017) were systematically searched. ELIGIBILITY CRITERIA All RCTs investigating the efficacy and safety of perineural DEX combined with local anaesthetics compared with local anaesthetics alone or local anaesthetics in combination with systemic DEX in peripheral nerve blocks of adults undergoing surgery were included. RESULTS A total of 46 RCTs (3149 patients) were included. Patients receiving perineural DEX combined with local anaesthetics had a longer duration of analgesia than local anaesthetics alone [mean difference 4.87 h; 95% confidence interval (95% CI) 4.02 to 5.73; P<0.001; I2=100%; moderate-quality evidence]. The most important adverse events in the DEX group were intraoperative bradycardia [risk ratio 2.83; 95% CI 1.50 to 5.33; P=0.035; I2=40%; very low-quality evidence] and hypotension (risk ratio 3.42; 95% CI 1.24 to 9.48; P=0.002; I2=65%; very low quality evidence). In contrast, there were no differences in the duration of analgesia between perineural or intravenous DEX combined with local anaesthetics (mean difference 0.98 h; 95% CI -0.12 to 2.08; P=0.08; I2=0%). CONCLUSION This meta-analysis demonstrated that DEX in combination with local anaesthetics increases postoperative analgesia for around 5 h. However, there are higher risks of intraoperative hypotension and bradycardia. Findings on side effects are associated with high uncertainty. Initial evidence suggests no difference in the duration of analgesia associated with systemic or perineural DEX.Copyright © 2018 European Society of Anaesthesiology. All rights reserved. Database: EMBASE

25. Ultrasound-guided single injection versus continuous sciatic nerve blockade on pain management and mobilisation after total knee arthroplasty (CoSinUS trial): A randomised, triple-blinded controlled trial Author(s): Wiesmann T.; Huttemann I.; Schilke N.; Wulf H.; Feldmann C.; Heyse T.; Efe T.; Eschbach D.; Steinfeldt T. Source: European Journal of Anaesthesiology; 2018; vol. 35 (no. 10); p. 782-791 Publication Date: 2018 Publication Type(s): Article Abstract:BACKGROUND: Combining continuous femoral nerve blockade with single injection sciatic nerve blockade is standard peripheral nerve block practice for total knee arthroplasty (TKA) during the first 24 postoperative hours. OBJECTIVE(S): To assess the analgesic benefits and mobilisation capability of continuous sciatic blockade in conjunction with continuous femoral nerve blockade for 72 h after arthroplasty. DESIGN: Randomised, triple-blinded controlled trial. SETTING Single-Centre, German University Hospital. PATIENTS: In total, 50 patients receiving continuous femoral nerve blockade (5mlh-1 ropivacaine 0.2%) for TKA under general anaesthesia. INTERVENTIONS: Patients were randomised to receive a sciatic nerve catheter with an initial dose of 10 ml ropivacaine 0.2% followed by either continuous double-blinded application of 5mlh-1 ropivacaine 0.2% (CO) or 5mlh-1 saline infusion (SIN). MAIN OUTCOME: Measures primary endpoint: cumulative morphine consumption until 48 h postoperatively. Further endpoints included morphine consumption, pain scores, mobilisation, dynamometry until postoperative day 3. RESULT(S): Median [25th to 75th percentiles] cumulative morphine consumption at postoperative day 2 differed significantly between groups (CO 15mg [11 to 25] versus SIN, 43 mg [27 to 67.5, P<0.0001) in the 48 patients in the final analysis. Overall pain scores were comparable at rest and during stress at each time point. However, significantly higher pain scores of the popliteal fossa were observed in the SIN group. Mobilisation was comparable between groups. CONCLUSION(S): This trial demonstrates the superior analgesic effects of continuous sciatic nerve block compared with a single injection in combination with continuous femoral blockade during the first 72 h after TKA. However, mobilisation capability was impaired in both groups. Improved pain control from two catheters needs to be balanced against the potential risks of impaired mobilisation and patient falls.Copyright © 2018 European Society of Anaesthesiology. All rights reserved. Database: EMBASE

26. Preoperative fascia iliaca block does not improve analgesia after arthroscopic hip surgery, but causes quadriceps muscles weakness: A randomized, double-blind trial Author(s): Behrends M.; Yap E.N.; Kolodzie K.; Kinjo S.; Harbell M.W.; Aleshi P.; Zhang A.L. Source: Anesthesiology; 2018; vol. 129 (no. 3); p. 536-543 Publication Date: 2018 Publication Type(s): Article Abstract:Background: Ambulatory hip arthroscopy is associated with postoperative pain routinely requiring opioid analgesia. The potential role of peripheral nerve blocks for pain control after hip arthroscopy is controversial. This trial investigated whether a preoperative fascia iliaca block improves postoperative analgesia. Method(s): In a prospective, double- blinded trial, 80 patients scheduled for hip arthroscopy were randomized to receive a preoperative fascia iliaca block with 40 ml ropivacaine 0.2% or saline. Patients also received an intraarticular injection of 10-ml ropivacaine 0.2% at procedure end. Primary study endpoint was highest pain score reported in the recovery room; other study endpoints were pain scores and opioid use 24 h after surgery. Additionally, quadriceps strength was measured to identify leg weakness. Result(s): The analysis included 78 patients. Highest pain scores in the recovery room were similar in the block group (6 +/- 2) versus placebo group (7 +/- 2), difference: -0.2 (95% CI, -1.1 to 0.7), as was opioid use (intravenous morphine equivalent dose: 15 +/- 7mg [block] vs. 16 +/- 9 mg [placebo]). Once discharged home, patients experienced similar pain and opioid use (13 +/- 7 mg [block] vs. 12 +/- 8 mg [placebo]) in the 24 h after surgery. The fascia iliaca block resulted in noticeable quadriceps weakness. There were four postoperative falls in the block group versus one fall in the placebo group. Conclusion(s): Preoperative fascia iliaca blockade in addition to intraarticular local anesthetic injection did not improve pain control after hip arthroscopy but did result in quadriceps weakness, which may contribute to an increased fall risk. Routine use of this block cannot be recommended in this patient population.Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Database: EMBASE

27. Enhanced Recovery After Surgery for Cardiac Surgery: Will We Have the Techniques Needed to Reduce Opioid Use and Still Provide Appropriate Analgesia? Author(s): Jellish W.S.; Oftadeh M. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

28. Postoperative thoracic and low back pain following endovascular aortic repair associated with stenting location Author(s): Miyoshi H.; Hamada H.; Nakamura R.; Kondo T.; Yasuda T.; Saeki N.; Kawamoto M. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: We have noted that patients frequently complain of thoracic or low back pain after undergoing an endovascular aortic repair, which we speculated was caused by the indwelling stent. Method(s): We investigated the patients who underwent an elective thoracic or abdominal endovascular aortic repair (TEVAR or EVAR) and noted the location of stent, and postoperative pain. The incidence of either thoracic or low back pain at individual vertebra levels was determined, after which we fitted the sigmoidal function to the discrete data to obtain a cut-off line. The study patients were then divided into 2 groups using the cut-off line to compare the incidence of pain. Result(s): We analyzed 96 patients (68 TEVAR, 28 EVAR). The incidence of thoracic pain was significantly higher in TEVAR as compared to EVAR (26.5% vs. 3.6%, P = 0.01), while that of low back pain was significantly higher in EVAR (35.7% vs. 16.2%, P = 0.04). With the cut-off line for thoracic pain set at the 12th thoracic vertebra, the incidence of thoracic pain was significantly higher in patients with the upper end of the stent above the cut-off as compared to at a lower point (26.5% vs. 3.6%, P = 0.01). As for low back pain, the cut-off line was set at the 9th thoracic vertebra, and the incidence of that pain was significantly higher in patients with the lower end of the stent below that line (30.9% vs. 0.0%, P < 0.01). Conclusion(s): Thoracic and low back pain after an endovascular aortic repair procedure were associated with stenting site.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

29. Risk Factors and Outcomes Associated With Sepsis After Coronary Artery Bypass and Open Heart Valve Surgeries Author(s): Karamnov S.; Brovman E.Y.; Greco K.J.; Urman R.D. Source: Seminars in Cardiothoracic and Vascular Anesthesia; Dec 2018; vol. 22 (no. 4); p. 359-368 Publication Date: Dec 2018 Publication Type(s): Review Abstract:Purpose. Sepsis causes significant morbidity and mortality after cardiac surgery and carries a significant burden on health care costs. There is a general association of increased risk of post-cardiac surgery sepsis in patients with postoperative complications. We sought to investigate significant patient and procedural risk factors and outcomes associated with sepsis after cardiac surgery. Materials and Methods. In this retrospective study, we analyzed 531 coronary artery bypass grafting and open heart valve surgery cases that developed postoperative sepsis in the National Surgical Quality Improvement Program database between 2007 and 2014. Patient-based and surgery-based parameters were analyzed for risk factors and outcomes reported in the 30 days postoperatively. The association between sepsis and patient outcomes was assessed in a propensity-matched cohort using univariable logistic regression. Results. Modifiable and nonmodifiable patient characteristics, including age >80, poor preoperative functional status, chronic diseases such as diabetes mellitus, congestive heart failure, chronic kidney disease with serum creatinine 1.5, as well as serum albumin <3.5 and emergent nature of the case were associated with post-cardiac surgery sepsis. Surgical outcomes associated with sepsis included mortality (15.4% vs 4.5%), unplanned intubation (29.8% vs 8.2%), transfusion (53.4% vs 48.4%), acute kidney injury (7.1% vs 1.4%), postoperative dialysis (18.8% vs 3.5%), and return to the operating room (29.8% vs 8.2%). Conclusions. We identified multiple patient and surgical characteristics as well as postoperative outcomes associated with postoperative sepsis development in the high-risk population of patients undergoing cardiac surgery. Early identification of patients who are at high risk for postoperative sepsis can facilitate early treatment interventions.Copyright © The Author(s) 2018. Database: EMBASE

30. Clinical characteristics and prognosis of serous body cavity effusions in patients with sepsis: A retrospective observational study 11 Medical and Health Sciences 1103 Clinical Sciences Author(s): Xing L.-Y.; Yin J.; Shao M.; Yang Y.-L.; Xue M.-M.; Mu S.-C.; Sun Z.; Zhang Y.-P.; Yao C.-L.; Tong C.-Y.; Song Z.-J.; Li K.-Y.; Chu X. Source: BMC Anesthesiology; Nov 2018; vol. 18 (no. 1) Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30428838 Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Abstract:Background: Cavity effusion is common in patients with infectious diseases. However, the incidence rate and characteristics of serous cavity effusions (SCE) in septic patients are not clear to date. The objective of this study was to investigate the incidence and characteristics of SCE in septic patients and to explore the correlations between the bloody effusions and the illness severity/prognosis in septic patients. Method(s): From January 2010 to January 2015, a total of 214 patients with severe sepsis and septic shock were enrolled in this retrospective observational study. Thoracentesis or abdominal paracentesis was performed in 45 septic patients because of massive pleural effusions or ascites. The serum concentrations of VEGF, VEGFR, Ang, sICAM-1, sVCAM-1, E-selectin, Serpine1 and VE-cadherin in 45 septic patients underwent paracentesis were measured by enzyme-linked immunosorbent assay (ELISA). Result(s): Of the 214 septic patients, 155 (72.4%) had SCE according to imaging or ultrasound manifestations. 45 subjects with SCE underwent therapeutic thoracentesis or abdominal paracentesis. Effusion laboratory analysis showed that exudates were predominant when compared with transudates (95.6% vs. 4.4%), and 16 (35.6%) patients suffered bloody effusions. Compared with patients with non-bloody effusions, those with bloody effusions showed higher critical illness scores (13 vs. 17 for APACHE II; 7 vs. 9 for SOFA), and higher mortality (6.9% vs. 62.5%). Moreover, patients with bloody effusions had delayed TT and APTT, increased D-dimer concentration, and higher serum levels of CRP and PCT (P < 0.05). In addition, the serum levels of Ang2, sVCAM-1 and E-selectin were significantly higher in patients with bloody effusions than in those with non-bloody effusions (P < 0.05). However, the serum level of VEGFR2 was lower in patients with bloody fluids (P = 0.025). Conclusion(s): The incidence of serous cavity effusion is high in patients with sepsis. The septic patients with bloody effusions suffer a more inflammatory burden and a worse prognosis compared to septic patients with non- bloody effusions.Copyright © 2018 The Author(s). Database: EMBASE

31. Dying as a pathway to death in sepsis Author(s): Zhang W.; Coopersmith C.M. Source: Anesthesiology; Aug 2018; vol. 129 (no. 2); p. 238-240 Publication Date: Aug 2018 Publication Type(s): Article Database: EMBASE

32. Airway management practice in adults with an unstable cervical spine: The harborview medical center experience Author(s): Holmes M.G.; Feinstein B.A.; Dagal A.; Joffe A.M. Source: Anesthesia and Analgesia; 2018; vol. 127 (no. 2); p. 450-454 Publication Date: 2018 Publication Type(s): Article Abstract:Background: Airway management in the presence of acute cervical spine injury (CSI) is challenging. Because it limits cervical spine motion during tracheal intubation and allows for neurological examination after the procedure, awake fiberoptic bronchoscopy (FOB) has traditionally been recommended. However, with the widespread availability of video laryngoscopy (VL), its use has declined dramatically. Our aim was to describe the frequency of airway management techniques used in patients with CSI at our level I trauma center and report the incidence of neurological injury attributable to airway management. Method(s): Adults presenting to the operating room with CSI without a tracheal tube in situ between September 2010 and June 2017 were included. All patients were intubated in the presence of manual-in-line stabilization, a hard cervical collar, or surgical traction. Worsening neurological status was defined as new motor or sensory deficits on postoperative examination. Result(s): Two hundred fifty-two patients were included, of which 76 (30.2%) had preexisting neurological deficits. VL was the most frequent initial airway management technique used (49.6%). Asleep FOB was commonly performed alone (30.6%) or in conjunction with VL (13.5%). Awake FOB was rarely performed (2.3%), as was direct laryngoscopy (2.8%). All techniques were associated with high first-attempt success rates, and no cases of neurological injury attributable to airway management technique were identified. Conclusion(s): Among patients with acute CSI at a high-volume academic trauma center, VL was the most commonly used initial intubation technique. Awake FOB and direct laryngoscopy were performed infrequently. No cases of neurological deterioration secondary to airway management occurred with any method. Assuming care is taken to limit neck movement, providers should use the intubation technique with which they have the most comfort and skill.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

33. Readiness for discharge after foot and ankle surgery using peripheral nerve blocks: A randomized controlled trial comparing spinal and general anesthesia as supplements to nerve blocks Author(s): YaDeau J.T.; Kahn R.L.; LaSala V.R.; Paroli L.; Luu T.H.; Fields K.G.; Ellis S.J.; Levine D.S.; Roberts M.M. Source: Anesthesia and Analgesia; 2018; vol. 127 (no. 3); p. 759-766 Publication Date: 2018 Publication Type(s): Article Abstract:Background: Neuraxial anesthesia is often viewed as superior to general anesthesia but may delay discharge. Comparisons do not typically use multimodal analgesics and nerve blockade. Combining nerve blockade with general anesthesia may reduce pain, opioid consumption, and nausea. We hypothesized that general anesthesia (with nerve blocks) would lead to earlier readiness for discharge, compared to spinal anesthesia (with nerve blocks). Method(s): All patients underwent ambulatory foot and ankle surgery, with a predicted case duration of 1-3 hours. All patients received popliteal and adductor canal nerve blocks using bupivacaine and dexamethasone. No intraoperative opioids were administered. All patients received ondansetron, dexamethasone, ketamine, and ketorolac. Patients, data collectors, and the data analyst were not informed of group assignment. Patients were randomized to spinal or general anesthesia with concealed allocation. Spinal anesthesia was performed with mepivacaine and accompanied with propofol sedation. After general anesthesia was induced with propofol, a laryngeal mask airway was inserted, followed by sevoflurane and propofol. Time until ready for discharge, the primary outcome, was compared between groups after adjusting for age and surgery time using multivariable unconditional quantile regression. Secondary outcomes compared at multiple timepoints were adjusted for multiple comparisons using the Holm-Bonferroni step-down procedure. Result(s): General anesthesia patients were ready for discharge at a median of 39 minutes earlier (95% confidence interval, 2-75; P = .038) versus spinal anesthesia patients. Patients in both groups met readiness criteria for discharge substantially before actual discharge. Pain scores at rest were higher among general anesthesia patients 1 hour after leaving the operating room (adjusted difference in means, 2.1 [95% confidence interval, 1.0-3.2]; P < .001). Other secondary outcomes (including opioid use, opioid side effects, nausea, headache, sore throat, and back pain) were not different. Conclusion(s): General anesthesia was associated with earlier readiness for discharge, but the difference may not be clinically significant and did not lead to earlier actual discharge. Most secondary outcomes were not different between groups. The choice of spinal or general anesthesia as an adjunct to peripheral nerve blockade can reflect patient, clinician, and institutional preferences.Copyright © 2018 International Anesthesia Research Society. Database: EMBASE

34. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial Author(s): Humphreys S.; Lee-Archer P.; Reyne G.; Long D.; Williams T.; Schibler A. Source: British journal of anaesthesia; Feb 2017; vol. 118 (no. 2); p. 232-238 Publication Date: Feb 2017 Publication Type(s): Article PubMedID: 28100527 Abstract:BACKGROUND: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) was introduced to adult anaesthesia to improve the safety of airway management during apnoea before intubation. The objective of our study was to determine whether THRIVE safely prolongs apnoeic oxygenation in children. METHOD(S): This was a randomized controlled trial in 48 healthy children, with normal airways and cardiorespiratory function, in age groups 0-6 and 7-24 months, 2-5 and 6-10yr old, presenting for elective surgery or imaging under general anaesthesia. All children were induced with sevoflurane, O2, and N2O, followed by muscle relaxation with rocuronium, and standardized preoxygenation with bag-and-mask ventilation. The control arm received jaw support during apnoea, whereas the THRIVE arm received jaw support during apnoea and age-specific flow rates. The primary outcome was to demonstrate that children allocated to THRIVE maintain transcutaneous haemoglobin saturation at least twice as long as the expected age- dependent apnoea time in the control group. RESULT(S): Both study arms (each n=24) were similar in age and weight. The apnoea time was significantly shorter in the control arm: average 109.2 (95% CI 28.8) s in the control arm and 192s in the THRIVE arm (0-6 months), 147.3 (95% CI 18.9) and 237s (7-24 months), 190.5 (95% CI 15.3) and 320s (2-5yr), and 260.8 (95% CI 37.5) and 430s (6-10yr), respectively. Average transcutaneous haemoglobin saturation remained at 99.6% (95% CI 0.2) during THRIVE. Transcutaneous CO2 increased to a similar extent in both arms, with 2.4 (95% CI 0.5) mm Hg min-1 for the control arm and 2.4 (95% CI 0.4) mm Hg min-1 for the THRIVE arm. CONCLUSION(S): Transnasal humidified rapid-insufflation ventilatory exchange prolongs the safe apnoea time in healthy children but has no effect to improve CO2 clearance. CLINICAL TRIAL REGISTRATION: ACTRN12615001319561.Copyright © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]. Database: EMBASE

35. Slow waves, cognitive disintegration, and delirium Author(s): Sleigh J.; Sanders R.W. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

36. Enhanced Recovery After Surgery: Are the Principles Applicable to Adult and Geriatric Acute Care and Trauma Surgery? Author(s): Singh M.; Askari R.; Stopfkuchen-Evans M. Source: Anesthesiology Clinics; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:The incorporation of enhanced recovery after surgery (ERAS) fundamentals into perioperative medicine has improved the patient care experience and hastened recovery time while reducing hospital costs. Research studies have shown that incorporating ERAS principles in the adult or geriatric acute care surgery populations minimizes time to resumption of preoperative activity and reduces hospital length of stay. ERAS principles are widely applicable to these patient cohorts and may be applicable in trauma patients. Increased physician and nursing education to promote widespread utilization of enhanced recovery protocols will further improve quality of health care administered in the twenty- first century.Copyright © 2018 Elsevier Inc. Database: EMBASE

37. Fibreoptic-guided tracheal intubation through i-gel and LMA Protector^TM supraglottic airway devices - a randomised comparison Author(s): Mendonca C.; Tourville C.C.; Nowicka A.; Patteril M.; Jefferson H.; Athanassoglou V. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Fibreoptic-guided tracheal intubation using a supraglottic airway device as a conduit is a technique that can be used in anticipated and unanticipated difficult airway management. Although the i-gel supraglottic airway device has been examined for this purpose, the LMA ProtectorTM, a recently introduced second-generation supraglottic airway device, has not been evaluated for this use in clinical trials. This prospective, randomised clinical trial compared fibreoptic-guided tracheal intubation via i-gel and LMA Protector supraglottic airway devices in two UK hospitals. Patients who were ASA physical status 1 or 2 and undergoing elective surgery requiring tracheal intubation were recruited to the study. A block randomisation list was generated for each study site. The primary outcome measure was time to successful tracheal intubation and secondary outcomes were tracheal intubation success rate, glottic view through flexible fibrescope, ease of tracheal intubation using operator visual analogue score, supraglottic airway device insertion time and insertion success rate. Ninety patients were randomly allocated to each device, and final data analysis was carried out for 92 patients in the i-gel group and 86 patients in the LMA Protector group. Mean (SD) tracheal intubation time in the i-gel and LMA Protector groups were 54.3 (13.8) s and 52.0 (13.0) s, respectively (p = 0.240). There were no significant differences in tracheal intubation success rate, glottic view and ease of tracheal intubation between the two groups. This study demonstrates that the LMA Protector supraglottic airway device is comparable to the i-gel supraglottic airway device as a conduit for fibreoptic-guided tracheal intubation.Copyright © 2018 Association of Anaesthetists Database: EMBASE

38. Micro-fragmented fat injection reduces sepsis-induced acute inflammatory response in a mouse model Author(s): Bougle A.; Rocheteau P.; Haroche A.; Briand D.; Mantz J.; Chretien F.; Hivelin M.; Tremolada C. Source: British Journal of Anaesthesia; Dec 2018; vol. 121 (no. 6); p. 1249-1259 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 30442252 Abstract:Background: Severe sepsis has a high mortality rate. There is increasing evidence that human mesenchymal stem cells possess immunomodulatory properties in sepsis, particularly those from adipose tissue. We hypothesised that micro-fragmented human fat, obtained with minimal alteration of the stromal vascular niche, attenuates the inflammatory response and improves outcome in a murine model of sepsis. Method(s): Micro-fragmented fat, lipoaspirate, or saline was administered intraperitoneally 2 h after caecal ligation and puncture (CLP) in C57Bl/6RJ ketamine-xylazine anaesthetised mice. The primary endpoint was the inflammatory score. Secondary endpoints included survival, physiological, histological, and biological parameters. Result(s): In CLP mice, micro-fragmented fat administration significantly decreased the median (range) inflammatory score compared with saline [17 (14-20) vs 9 (8-12), P=0.006]. Secondary endpoints were also significantly improved in micro-fragmented fat-treated compared with saline-treated CLP mice. Improvement in inflammatory score and in survival was suppressed when micro-fragmented fat was co-administered with liposomes loaded with clodronate (macrophage toxin) or NS- 398 (cyclo-oxygenase 2 inhibitor), but not with SC-560 (cyclo-oxygenase 1 inhibitor). Conclusion(s): In a murine model of severe sepsis, micro-fragmented fat improved early inflammatory status and outcome, at least in part, by a cyclo-oxygenase-2-mediated mechanism. The potential therapeutic value of micro-fragmented fat in severe sepsis warrants further investigation.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

39. Low-concentration distal nerve blocks with 0.125% levobupivacaine versus systemic analgesia for ambulatory trapeziectomy performed under axillary block: A randomized controlled trial Author(s): Rodriguez Prieto M.; Gonzalez F.J.; Garcia M.; Font A.; Moreno M.; Gildebernabe M.A.; Moral M.V.; Hoffmann R.; Sabate S.; Lamas C.; Proubasta I. Source: Minerva Anestesiologica; Nov 2018; vol. 84 (no. 11); p. 1261-1269 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29405670 Abstract:BACKGROUND: Trapeziectomy is one of the most painful procedures in ambulatory surgery. This prospective randomized trial aimed to compare postoperative pain control using distal peripheral nerve blocks (dPNB) with a low concentration of a long-acting local anesthetic versus conventional systemic analgesia. METHOD(S): Fifty-two patients undergoing trapeziectomy were randomized to receive levobupivacaine 0.125% 5 mLon radial and median nerves at the elbow (dNB group), or not to receive these blocks (control group). In both groups, surgery was performed under axillary block (mepivacaine 1% 20 mL) and the same analgesic regimen was prescribed at discharge. The primary outcome was postoperative pain at 24 and 48 hours after surgery and maximum pain score on the first and second postoperative day. Secondary outcomes were duration of dPNB, rescue analgesia requirements, opioid-related side effects, consumption and effectiveness of antiemetic therapy, and upper limb motor block. RESULT(S): Fifty patients were analyzed. Maximum pain intensity was moderate to severe (dPNB vs. control) in 33.3% vs. 92.3% (P=0.002) on the first day after surgery and 20.8% vs. 80.8% (P<0.001) on the second day. The average duration of analgesia after dPNB was 10 hours and no patient reported motor block. dPNB reduced rescue analgesia requirements and the incidence of postoperative nausea and vomiting (PONV). CONCLUSION(S): dPNB on target nerves provided better analgesia than systemic analgesia after trapeziectomy performed under axillary block. Opioid consumption and the incidence of PONV were lower in the dPNB group.Copyright © 2018 EDIZIONIMINERVAMEDICA. Database: EMBASE

40. Airway management research: a systematic review Author(s): Ahmad I.; Onwochei D.N.; El-Boghdadly K.; Muldoon S.; Keane O. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Recent controversy regarding the ethics of conducting airway research in patients led to disagreements concerning the value and frequency of manikin-based investigation. However, no formal examination of the methodology of airway research has been undertaken. We, therefore, performed a systematic bibliometric review of airway management research to describe the conduct, quantify the subjects (patient vs. manikin vs. other), assess the reported outcomes and map global trends. We retrieved 1505 relevant studies published between 2006 and 2017, together recruiting 359,648 subjects, of which 341,233 were patients, the remaining being volunteers or subjects managing manikins, human cadavers, animals or bench models. There were 701 randomised controlled clinical trials (46.6%), 83 non-randomised experimental clinical trials (5.5%), 298 observational studies (19.8%) and 423 non-patient studies (28.1%). A total of 1082 studies (71.9%) were patient studies and 322 were manikin studies (21.4%). The total annual number of airway management studies increased over time, as did the annual number of patient studies, but there was no significant increase in the annual number of manikin studies over time. Of the patient studies, subject baseline characteristics were most likely to be ASA status 1-2 (n = 531, 49.1%), populations were most often elective surgical patients (n = 918, 84.8%) and the most common interventions studied were tracheal intubation (n = 820, 54.4%) or supraglottic airway device insertion (n = 257, 17.1%). There was a total of 77 different primary outcomes used in the included studies, the most commonly reported being success rate and procedure time. By understanding how and what has been previously studied these data can be used to form the basis for future priority setting exercises, core outcome set development, and could inform strategy on the future directions of airway management research.Copyright © 2018 Association of Anaesthetists Database: EMBASE

41. Co-administration of dexamethasone with peripheral nerve block: intravenous vs perineural application: systematic review, meta-analysis, meta-regression and trial- sequential analysis Author(s): Heesen M.; Klimek M.; Hoeks S.E.; Imberger G.; Rossaint R.; Straube S. Source: British Journal of Anaesthesia; Feb 2018; vol. 120 (no. 2); p. 212-227 Publication Date: Feb 2018 Publication Type(s): Review Abstract:Background: I.V. and perineural dexamethasone have both been found to prolong loco-regional analgesia compared with controls without dexamethasone. It is unclear whether perineural administration offers advantages when compared with i.v. dexamethasone. Method(s): A systematic literature search was performed to identify randomized controlled double-blind trials that compared i.v. with perineural dexamethasone in patients undergoing surgery. Using the random effects model, risk ratio (for binary variables), weighted mean difference (for continuous variables) and 95% confidence intervals were calculated. We applied trial sequential analysis to assess the risks of type I and II error, meta-regression for the study of the doseresponsive relationship, and the Grading of Recommendations Assessment, Development, and Evaluation system. Result(s): We identified 10 randomized controlled double-blind trials (783 patients). When using conventional meta-analysis of nine low risk of bias trials, we found a statistically significantly longer duration of analgesia, our primary outcome with perineural dexamethasone (241 min, 95%CI, 87, 394 min). When trial sequential analysis was applied, this result was confirmed. Meta-regression did not show a dose-response relationship. Despite the precision in the results, using the Grading of Recommendations Assessment, Development, and Evaluation system (GRADE), we assessed the quality of the evidence for our primary outcome as low. Conclusion(s): There is evidence that perineural dexamethasone prolongs the duration of analgesia compared with i.v. dexamethasone. Using GRADE, this evidence is low quality.Copyright © 2017 Database: EMBASE

42. Local anaesthetic dosage of peripheral nerve blocks in children: analysis of 40 121 blocks from the Pediatric Regional Anesthesia Network database Author(s): Suresh S.; De Oliveira G.S. Source: British Journal of Anaesthesia; Feb 2018; vol. 120 (no. 2); p. 317-322 Publication Date: Feb 2018 Publication Type(s): Article Abstract:Background: The knowledge regarding appropriate dosage of local anaesthetics for peripheral nerve blocks in children is very scarce. The main objective of the current investigation was to evaluate dosing patterns of local anaesthetics in children receiving peripheral nerve blocks across multiple paediatric hospitals in the USA. We also sought to estimate the incidence of local anaesthetic systemic toxicity. Method(s): This is an observational study using the Pediatric Regional Anesthesia Network (PRAN) database. Data on every peripheral nerve block in patients aged <18 years placed from April 1, 2007 to May 31, 2015 were examined as a subset of the PRAN protocol. Data were examined for the type and dose of local anaesthetic and for the presence of local anaesthetic systemic toxicity. Result(s): In total, 40 121 peripheral nerve blocks in children were analysed. Individual analyses of block type demonstrated large local anaesthetic dose variability with a five- to 10-fold spread depending on the block type. Two patients developed local anaesthetic systemic toxicity, resulting in an estimated incidence (95% CI) per blocks performed of 0.005% (0.001-0.015%). None of the patients had any short- or long-term complications or sequelae. Conclusion(s): We detected a large variability in the local anaesthetic dosing practices for peripheral nerve blocks in children across multiple hospitals in the USA. Nonetheless, the risk of local anaesthetic systemic toxicity was very low. Due to the lack of dose findings studies, our results suggest the need to develop practice guidelines to minimize variability of regional anaesthesia practices in children.Copyright © 2017 British Journal of Anaesthesia Database: EMBASE

43. Could patient-controlled thirst-driven fluid administration lead to more rapid rehydration than clinician-directed fluid management? An early feasibility study Author(s): Hughes F.; Ng S.C.; Mythen M.; Montgomery H. Source: British Journal of Anaesthesia; Feb 2018; vol. 120 (no. 2); p. 284-290 Publication Date: Feb 2018 Publication Type(s): Article Abstract:Background: Fluid management is a major factor determining perioperative outcome, yet in reality, fluid administration practice is variable. Thirst however, is a highly sensitive and reliable indicator of fluid deficits. We explored the use of thirst sensation to trigger i.v. fluid boluses to guide individualized fluid management. Method(s): We performed a randomised double crossover trial on 16 healthy male volunteers, of mean age 31 yr and BMI 24.4 kg m-2. Twice, after administrations of oral furosemide (40 mg) and 12 h of oral fluid restriction, participants received a 4-h i.v. fluid infusion. In the experimental arm, participants pressed a trigger to relieve their thirst, administering a 200 ml bolus. In the control arm, i.v. fluid was infused following National Institute for Health and Clinical Excellence (NICE) guidelines at 1.25 ml kg-1 h-1 with a clinician delivered 500 ml i.v. bolus in response to clinical signs of dehydration. Plasma osmolality and urine specific gravity were measured before and after each infusion. Result(s): More fluid was infused in response to thirst than by adherence to NICE guidelines, with a mean difference of 743 ml (P=0.0005). Thirst-driven fluid administration was fitted to an exponential function of time, plateauing after a mean half-life of 98.8 min. In the experimental arm there was a greater reduction in urine specific gravity and thirst score with mean differences 0.0053 g cm-3 (P=0.002) and 3.3 (P=0.003), respectively. Plasma osmolality demonstrated no fluid overload. Conclusion(s): A system delivering i.v. fluid in response to subjective thirst corrects fluid deficits in healthy participants. A clinical feasibility study will assess the potential use of this system in the perioperative setting. Clinical trial registration: NCT 03176043.Copyright © 2017 British Journal of Anaesthesia Database: EMBASE

44. Intravenous dexamethasone fails to prolong psoas compartment block when assessed by objective pinprick sensory testing: a prospective, randomised, dose-dependent, placebo-controlled equivalency trial Author(s): Turner J.D.; Dobson S.W.; Weller R.S.; Henshaw D.S.; Russell G.B. Source: British Journal of Anaesthesia; Feb 2018; vol. 120 (no. 2); p. 308-316 Publication Date: Feb 2018 Publication Type(s): Article Abstract:Background: Recent studies have concluded that i.v. dexamethasone can prolong the duration of peripheral nerve blockade. We hypothesized that a 4 mg dose would equally prolong the duration of psoas compartment blocks (PCBs) when compared with 8 mg, and that both doses would prolong the duration when compared with placebo. Method(s): This was a prospective, randomized, placebo-controlled, dose-dependent, equivalency trial with 115 patients undergoing total hip arthroplasty. The patients received a PCB. Subsequently, 15 patients received i.v. normal saline (placebo), 50 patients received i.v. dexamethasone 4 mg, and 50 patients received i.v. dexamethasone 8 mg. The primary outcome was the duration in hours of PCB, determined by serial pinprick assessments. Secondary outcomes included pain scores, time to first analgesic, and opioid consumption. An intention-to-treat- analysis (ITA) and per-protocol analysis (PPA) were performed. Result(s): The ITA showed that block duration in the 4 and 8 mg groups was equivalent [mean (standard deviation), 18.5 h (8.0) vs 18.1 h (7.1)]. However, neither group differed from placebo [19.6 h (6.7), (4 mg vs placebo), P=0.97; (8 mg vs placebo), P=0.77)]. Postoperative pain scores and opioid consumption were not different between groups. Time to first analgesic was not different between the 4 and 8 mg groups, or the 4 mg and placebo groups. The 8 mg group, however, had a longer time to first analgesic (median of 533 vs 432 min, P=0.047) when compared with placebo, although the significance was not observed in the PPA (P=0.058). Conclusion(s): I.V. dexamethasone did not prolong PCB when duration was objectively assessed, or decrease total opioid consumption. However, dexamethasone 8 mg prolonged the time to first analgesic. Clinical trial registration: NCT 02464176.Copyright © 2017 British Journal of Anaesthesia Database: EMBASE

45. Current concepts of fluid management in enhanced recovery pathways Author(s): Makaryus R.; Gan T.J.; Miller T.E. Source: British Journal of Anaesthesia; Feb 2018; vol. 120 (no. 2); p. 376-383 Publication Date: Feb 2018 Publication Type(s): Review Abstract:Perioperative fluid management impacts outcomes and plays a pivotal role in enhanced recovery pathways (ERPs). There have been major advances in understanding the effects of fluid therapy and administration during the perioperative period. Improving fluid management during this period leads to a decrease in complications, decrease in length of stay (LOS), and enhanced patient outcomes. It is important to consider preoperative and postoperative fluid management to be just as critical as intraoperative management given multiple associated benefits to the patients. Preoperative hydration with (complex) carbohydrate drinks up until 2 h before surgery is safe and should be encouraged, as this helps improve metabolism, decrease insulin resistance, reduce anxiety, and reduce nausea and vomiting. During the intraoperative period, the goals of fluid management are to maintain euvolemia using an individualized plan for fluid and haemodynamic management, matching the needs for monitoring with patient and surgical risk through goal-directed therapy (GDT). By combining the use of fluids and inotropes, GDT uses measurements and indicators of cardiac output and stroke volume to improve blood flow intraoperatively, and ultimately reduce LOS and complications. In the postoperative period, an early transition to oral hydration helps to enhance the conditions for healing and recovery from surgery. I.V. fluid therapy should be kept at a minimum, and urine output should not be the driving force for fluid administration. The optimization of perioperative fluid management is critical to ERPs as it helps improve pulmonary function, tissue oxygenation, gastrointestinal motility, and wound healing.Copyright © 2017 British Journal of Anaesthesia Database: EMBASE

46. Perioperative management of tracheocutaneous fistula closure in children: A review of 96 cases Author(s): Ferns J.M.; Khan M.; Gupta S.; Smith J.H. Source: Paediatric Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pediatric Anesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: A tracheocutaneous fistula is a known complication following tracheostomy decannulation. Although surgical techniques for its repair are well described, there is no consensus about perioperative management and this procedure may generate significant airway and respiratory complications intraoperatively, and in the early postoperative period. We aimed to describe variations in perioperative management in tracheocutaneous fistula closure, estimate the incidence of early airway and respiratory complications, and identify any predisposing factors. Method(s): The otorhinolaryngology surgical database identified 118 tracheocutaneous fistula closures from August 1994 to September 2015. Ninety-seven case notes were located generating 96 procedures for retrospective review. The data collected included demographics, comorbidities, anesthetic, and surgical technique, and complications up to 24 hours postoperatively. Result(s): The median age at surgery was 5 years 10 months (range 1 year 8 months to 19 years 6 months). Preoperatively, 72% of patients had a "mini" sleep study (where the tracheocutaneous fistula is covered and saturations measured overnight). Ninety percent had an inhalational induction and 96% a tracheal intubation. Intraoperatively, laryngospasm occurred in 2% and there was difficulty ventilating in another 2%. A "leak test" to check fistula repair airtightness was recorded in 35%. Postoperatively 24% had one or more episodes of oxygen desaturation. Major complications occurred in five patients (incidence 5%, 95% CI 0.8-9.7); four patients had pneumothoraxes with two needing postoperative mechanical ventilation and one patient developed life-threatening subcutaneous emphysema. Conclusion(s): Perioperative care for children undergoing tracheocutaneous fistula closure was not standardized. Advocated tests such as preoperative "mini" sleep studies and "leak test" intraoperatively were not consistently performed. Intraoperative anesthetic complications were uncommon; however, major postoperative respiratory complications were 5%.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

47. Just the facts the role of diagnostic blocks in lumbar facet interventions Author(s): Brummett C.M.; Clark J.D. Source: Anesthesiology; 2018; vol. 129 (no. 3); p. 396-398 Publication Date: 2018 Publication Type(s): Review Database: EMBASE

48. Incidence and outcomes of sepsis after cardiac surgery as defined by the Sepsis-3 guidelines Author(s): Howitt S.H.; Malagon I.; McCollum C.N.; Grant S.W.; Herring M. Source: British Journal of Anaesthesia; Mar 2018; vol. 120 (no. 3); p. 509-516 Publication Date: Mar 2018 Publication Type(s): Article PubMedID: 29452807 Abstract:Background: The Sepsis-3 guidelines diagnose sepsis based on organ dysfunction in patients with either proven or suspected infection. The objective of this study was to assess the incidence and outcomes of sepsis diagnosed using these guidelines in patients in a cardiac intensive care unit (CICU) after cardiac surgery. Method(s): Daily sequential organ failure assessment (SOFA) scores were calculated for 2230 consecutive adult cardiac surgery patients between January 2013 and May 2015. Patients with an increase in SOFA score of >=2 and suspected or proven infection were identified. The length of CICU stay, 30-day mortality and 2-yr survival were compared between groups. Multivariable linear regression, multivariable logistic regression, and Cox proportional hazards regression were used to adjust for possible confounders. Result(s): Sepsis with suspected or proven infection was diagnosed in 104 (4.7%) and 107 (4.8%) patients, respectively. After adjustment for confounding variables, sepsis with suspected infection was associated with an increased length of CICU stay of 134.1h (95% confidence interval (CI) 99.0-168.2, P<0.01) and increased 30-day mortality risk (odds ratio 3.7, 95% CI 1.1-10.2, P=0.02). Sepsis with proven infection was associated with an increased length of CICU stay of 266.1h (95% CI 231.6- 300.7, P<0.01) and increased 30-day mortality risk (odds ratio 6.6, 95% CI 2.6-15.7, P<0.01). Conclusion(s): Approximately half of sepsis diagnoses were based on proven infection and half on suspected infection. Patients diagnosed with sepsis using the Sepsis-3 guidelines have significantly worse outcomes after cardiac surgery. The Sepsis-3 guidelines are a potentially useful tool in the management of sepsis following cardiac surgery.Copyright © 2017 British Journal of Anaesthesia Database: EMBASE

49. Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis Author(s): Guo L.; Xie J.; Huang Y.; Pan C.; Yang Y.; Qiu H.; Liu L. Source: BMC anesthesiology; Nov 2018; vol. 18 (no. 1); p. 172 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30447683 Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Abstract:BACKGROUND: Mortality in patients with acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation strategies that include high positive end-expiratory pressure (PEEP). It remains controversial whether high PEEP can improve outcomes for ARDS patients, especially patients who show improvement in oxygenation in response to PEEP. In this meta-analysis, we aimed to evaluate the effects of high PEEP on ARDS patients. METHOD(S): We electronically searched randomized controlled trials (RCTs) reported in the MEDLINE, CENTRAL, EMBASE, CINAHL and Web of Science databases from January 1990 to December 2017. Meta-analyses of the effects of PEEP on survival in adults with ARDS were conducted using the methods recommended by the Cochrane Collaboration. RESULT(S): A total of 3612 patients from nine randomized controlled trials (RCTs) were included. There were 1794 and 1818 patients in the high and low PEEP groups, respectively. Hospital mortality showed no significant difference between the high and low PEEP groups (RR=0.92; 95% CI, 0.79 to 1.07; P=0.26). Similar results were found for 28-d mortality (RR=0.88; 95% CI, 0.72 to 1.07; P=0.19) and ICU mortality (RR=0.83; 95% CI, 0.65 to 1.07; P=0.15). The risk of clinically objectified barotrauma was not significantly different between the high and low PEEP groups (RR=1.24; 95% CI, 0.74 to 2.09, P=0.41). In the subgroup of ARDS patients who responded to increased PEEP by improved oxygenation (from 6 RCTs), high PEEP significantly reduced hospital mortality (RR=0.83; 95% CI 0.69 to 0.98; P=0.03), ICU mortality (RR=0.74; 95% CI, 0.56 to 0.98; P=0.04),but the 28-d mortality was not decreased(RR=0.83; 95% CI, 0.67 to 1.01; P=0.07). For ARDS patients in the low PEEP group who received a PEEP level lower than 10 cmH2O (from 6 RCTs), ICU mortality was lower in the high PEEP group than the low PEEP group (RR=0.65; 95% CI, 0.45 to 0.94; P=0.02). CONCLUSION(S): For ARDS patients who responded to increased PEEP by improved oxygenation, high PEEP could reduce hospital mortality, ICU mortality and 28-d mortality. High PEEP does not increase the risk of clinically objectified barotrauma. Database: EMBASE

50. Use of the LMA GastroTM Airway, a novel dual channel laryngeal mask airway, for endoscopic retrograde cholangiopancreatography: a report of two cases Author(s): Galloway P.S.; McGlone D.J.; Middleton C.; Skinner M.W. Source: Anaesthesia and intensive care; Nov 2018; vol. 46 (no. 6); p. 632 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30447679 Database: EMBASE

51. Retrieval of critically ill adults using extracorporeal membrane oxygenation: the nine- year experience in New South Wales Author(s): Austin D.E.; Burns B.; Lowe D.; Cartwright B.; Clarke A.; Dennis M.; D'Souza M.; Nathan R.; Bannon P.G.; Gattas D.; Connellan M.; Forrest P. Source: Anaesthesia and intensive care; Nov 2018; vol. 46 (no. 6); p. 579-588 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30447667 Abstract:In New South Wales, a coordinated extracorporeal membrane oxygenation (ECMO) retrieval program has been in operation since 2007. This study describes the characteristics and outcomes of patients transported by this service. We performed a retrospective observational study and included patients who were transported on ECMO to either of two adult tertiary referral hospitals in Sydney, New South Wales, between February 28, 2007 and February 29, 2016. One hundred and sixty-four ECMO-facilitated transports occurred, involving 160 patients. Of these, 118 patients (74%) were treated with veno-venous (VV) ECMO and 42 patients (26%) were treated with veno-arterial ECMO. The mean (standard deviation, SD) age was 40.4 (15.0) years. Seventy-seven transports (47%) occurred within metropolitan Sydney, 52 (32%) were from rural or regional areas within NSW, 17 (10%) were interstate transfers and 18 (11%) were international transfers. Transfers were by road (58%), fixed wing aircraft (27%) or helicopter (15%). No deaths occurred during transport. The median (interquartile range) duration of ECMO treatment was 8.9 (5.2-15.3) days. One hundred and nineteen patients (74%) were successfully weaned from ECMO and 109 (68%) survived to hospital discharge or transfer. In patients treated with VV ECMO, age, sequential organ failure assessment score, pre-existing immunosuppressive disease, pre-existing diabetes, renal failure requiring dialysis and failed prone positioning prior to ECMO were independently associated with increased mortality. ECMO-facilitated patient transport is feasible, safe, and results in acceptable short-term outcomes. The NSW ECMO Retrieval Service provides specialised support to patients with severe respiratory and cardiovascular illness, who may otherwise be too unstable to undergo inter-hospital transfer to access advanced cardiovascular and critical care services. Database: EMBASE

52. Feasibility of automated titration of vasopressor infusions using a novel closed-loop controller Author(s): Rinehart J.; Ma M.; Calderon M.-D.; Cannesson M. Source: Journal of clinical monitoring and computing; Feb 2018; vol. 32 (no. 1); p. 5-11 Publication Date: Feb 2018 Publication Type(s): Article PubMedID: 28124225 Abstract:Blood pressure management is a central concern in critical care patients. For a variety of reasons, titration of vasopressor infusions may be an ideal use-case for computer assistance. Using our previous experience gained in the bench-to-bedside development of a computer-assisted fluid management system, we have developed a novel controller for this purpose. The aim of this preliminary study was to assess the feasibility of using this controller in simulated patients to maintain a target blood pressure in both stable and variable blood-pressure scenarios. We tested the controller in two sets of simulation scenarios: one with stable underlying blood pressure and a second with variable underlying blood pressure. In addition, in the variable phase of the study, we tested infusion-line delays of 8-60 s. The primary outcome for both testing conditions (stable and variable) was % case time in target range. We determined a priori that acceptable performance on the first phase of the protocol would require greater than 95% case-time in-target given the simple nature of the protocol, and for the second phase of the study 80% or greater given the erratic nature of the blood pressure changes taking place. 250 distinct cases for each simulation condition, both managed and unmanaged, were run over 4 days. In the stable hemodynamic conditions, the unmanaged group had an MAP of 57.5+/-4.6 mmHg and spent only 5.6% of case time in-target. The managed group had an MAP of 70.3+/-2.6 and spent a total of 99.5% of case time in-target (p<0.00001 for both comparisons between groups). In the variable hemodynamic conditions, the unmanaged group had an MAP of 53.1+/-5.0 mmHg and spent 0% of case time in-target. The managed group had an MAP of 70.5+/-3.2 mmHg (p<0.00001 compared to unmanaged group) and spent 88.6% of case time in-target (p<0.00001 compared to unmanaged group), with 6.4% of case time over and 5.1% of case time under target. Increasing infusion lag increased coefficient of variation by about 10% per 15 s of lag (p=0.001). This study demonstrated that this novel controller for vasopressor administration is able to main a target mean arterial pressure in a simulated physiologic model in the face of random disturbances and infusion-line lag. Database: EMBASE

53. Use of the Bougie Endotracheal Tube Introducer in Unstable Cervical Spine Airway Management? Author(s): Stephens C.T.; De Haan J.B.; Gumbert S.D.; Pivalizza E.G. Source: Anesthesia and analgesia; Dec 2018; vol. 127 (no. 6) Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 30300180 Database: EMBASE

54. Tranexamic Acid Dosing for Cardiac Surgical Patients With Chronic Renal Dysfunction: A New Dosing Regimen Author(s): Jerath A.; Wijeysundera D.; Beattie W.S.; Wasowicz M.; Yang Q.J.; Pang K.S.; Looby N.; Reyes-Garces N.; Vasiljevic T.; Bojko B.; Pawliszyn J.; Yau T.M. Source: Anesthesia and analgesia; Dec 2018; vol. 127 (no. 6); p. 1323-1332 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 29309319 Abstract:BACKGROUND: Tranexamic acid (TXA) is a common antifibrinolytic agent used to minimize bleeding in cardiac surgery. Up to 50% cardiac surgical patients have chronic renal dysfunction (CRD). Optimal dosing of TXA in CRD remains poorly investigated. This is important as TXA is renally eliminated with accumulation in CRD. High TXA doses are associated with postoperative seizures. This study measures plasma TXA concentrations in CRD cardiac surgical patients for pharmacokinetic modeling and dose adjustment recommendations. METHOD(S): This prospective cohort study enrolled 48 patients with stages 1-5 CRD, classified by Kidney Disease Outcome Quality Initiative. Patients were separated into 2 treatment groups. A "low-risk" group underwent simple aortocoronary bypass or single-valve repair/replacement and received a 50 mg/kg TXA bolus. A "high-risk" group underwent redo, aortic, multiple valve or combination surgery and received the Blood Conservation Using Anti-fibrinolytics Trial dosing regimen (loading dose 30 mg/kg, infusion 16 mg/kg/h with 2 mg/kg in pump prime). Primary outcome identified changes in TXA clearance and distribution volume, which provided the rationale for dose adjustment. Descriptive clinical outcomes assessed postoperative seizures, blood loss, ischemic- thrombotic complications, in-hospital mortality, and length of hospital stay. RESULT(S): TXA concentrations were elevated and sustained above the therapeutic threshold for approximately 12 hours in high-risk stages 3-5 groups, in accordance to CRD severity. CONCLUSION(S): Using a pharmacokinetic model, we propose a simple new TXA dosing regimen that optimizes maximal antifibrinolysis and avoids excessive drug dosing. Database: EMBASE

55. Operant Learning Versus Energy Conservation Activity Pacing Treatments in a Sample of Patients With Fibromyalgia Syndrome: A Pilot Randomized Controlled Trial Author(s): Racine M.; Harth M.; Nielson W.R.; Jensen M.P.; Morley-Forster P. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:This study's aim was to assess the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome (FMS). Treatment-related changes in activity management patterns were also examined. Patients with FMS (n = 178) were randomly assigned to an operant learning (OL; delayed [n = 36] or immediate [n = 54] groups) or an energy conservation (EC; delayed [n = 35] or immediate [n = 53] groups) treatment condition. Of these, 32 OL and 37 EC patients completed treatment. Forty-three patients were allocated to the delayed treatment condition (control group). Repeated measures analyses of variance were used to examine the effects of OL and EC treatments on primary (average pain and usual fatigue), secondary (pain and fatigue interference, physical and psychological function, sleep quality, depressive symptoms, and anxiety symptoms), and tertiary (pain- related activity patterns) outcomes. Neither treatment was effective in reducing average pain or usual fatigue symptoms. Relative to EC, OL patients showed greater improvements in depressive symptoms, whereas nonsignificant trends (P values ranging between.05 and.06) were observed for pain interference, fatigue interference, and psychological function. Both treatments were associated with improvements in sleep quality and physical function, increases in pacing, and decreases in overdoing activity patterns. Reductions in activity avoidance were only found in OL. These findings suggest that OL may be more beneficial than EC and that it could potentially be viewed as an effective stand-alone activity pacing treatment for patients with FMS. Research to determine the extent to which these preliminary findings replicate is warranted. Perspective(s): This article examines the efficacy of 2 forms of activity pacing in patients with fibromyalgia syndrome. The results suggest the possibility that operant learning may be more beneficial than energy conservation and could potentially be viewed as an effective stand-alone activity pacing treatment for patients with fibromyalgia syndrome.Copyright © 2018 Database: EMBASE

56. Three versus five lumbar paravertebral injections for inguinal hernia repair in the elderly: a randomized double-blind clinical trial Author(s): Naja Z.; Kanawati S.; Khatib Z.E.; Ziade F.; Nasreddine R.; Naja A.S. Source: Journal of Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Purpose: The objective of the study was to compare three nerve stimulator-guided paravertebral injections versus five injections for elderly patients undergoing inguinal hernia repair in terms of the amount of intraoperative fentanyl and propofol consumption and conversion to general anesthesia. The secondary objective was postoperative pain. Method(s): A prospective, randomized, double-blind clinical trial was performed. 200 elderly patients undergoing unilateral herniorrhaphy were randomized into two groups. Group III received three PVB injections from T12 to L2 and placebo at T11 and L3. Group V received five PVB injections from T11 to L3. Result(s): The mean intraoperative fentanyl and propofol consumption were significantly lower in group V (4.9 +/- 7.2 micro g versus 20.0 +/- 12.9 micro g and 5.7 +/- 11.6 mg versus 34.6 +/- 22.9 mg, respectively, p value < 0.0001). Five patients (5.0%) in group III had failed block and were converted to general anesthesia (p value = 0.024). Group V had significantly lower pain scores compared to group III during the first three postoperative days (p value < 0.0001). Conclusion(s): The five PVB injection technique is more suitable as a sole anesthetic technique for elderly patients undergoing herniorrhaphy, since it required less intraoperative supplemental analgesia and provided lower postoperative pain scores compared to the three PVB injection technique. Trial registration: Clinicaltrials.gov identifier: NCT02537860.Copyright © 2018, Japanese Society of Anesthesiologists. Database: EMBASE

57. Cytokine Gene Polymorphisms Associated With Various Domains of Quality of Life in Women With Breast Cancer Author(s): Alexander K.; Conley Y.P.; Levine J.D.; Cooper B.A.; Paul S.M.; Mastick J.; West C.; Miaskowski C. Source: Journal of Pain and Symptom Management; Feb 2018; vol. 55 (no. 2); p. 334 Publication Date: Feb 2018 Publication Type(s): Article Abstract:Context: Little is known about the phenotypic and molecular characteristics associated with various domains of quality of life (QOL) in women after breast cancer surgery. Objectives: In a sample of women with breast cancer (n = 398), purposes were as follows: to identify latent classes with distinct trajectories of QOL from before surgery through six months after surgery and to evaluate for differences in demographic and clinical characteristics, as well as for polymorphisms in cytokine genes, between these latent classes. Methods: Latent class analyses were done to identify subgroups of patients with distinct QOL outcomes. Candidate gene analyses were done to identify cytokine gene polymorphisms associated with various domains of QOL (i.e., physical, psychological, spiritual, social). Results: One latent class was identified for the psychological and spiritual domains. Two latent classes were identified for the social domain and overall QOL scores. Three latent classes were identified for the physical domain. For the physical and social domains, as well as for the overall QOL scores, distinct phenotypic characteristics (i.e., younger age, poorer functional status, higher body mass index, and receipt of adjuvant chemotherapy) and a number of cytokine gene polymorphisms (CXCL8, NFKB2, TNFSF, IL1B, IL13, and NFKB1) were associated with membership in the lower QOL classes. Conclusions: Findings suggest that women experience distinctly different physical well-being, social well- being, and total QOL outcomes during and after breast cancer surgery. The genetic associations identified suggest that cytokine dysregulation influences QOL outcomes. However, specific QOL domains may be impacted by different cytokines.Copyright © 2017 American Academy of Hospice and Palliative Medicine Database: EMBASE

58. Effects of Androgen Deprivation Therapy on Pain Perception, Quality of Life, and Depression in Men With Prostate Cancer Author(s): Gagliano-Juca T.; Manley R.; Hally K.; Bearup R.; Beleva Y.M.; Huang G.; Basaria S.; Travison T.G.; Nguyen P.L.; Kantoff P.W.; Taplin M.-E.; Kibel A.S.; Edwards R.R. Source: Journal of Pain and Symptom Management; Feb 2018; vol. 55 (no. 2); p. 307 Publication Date: Feb 2018 Publication Type(s): Article Abstract:Context: Previous animal and human research suggests that testosterone has antinociceptive properties. Castration in male rodents increases pain perception which is reversed by testosterone replacement. Pain perception also improves in hypogonadal men with testosterone therapy. However, it remains unclear whether androgen deprivation therapy (ADT) in men with prostate cancer (PCa) is associated with an increase in pain perception. Objectives: To evaluate the effects of ADT on pain perception, depression and quality of life (QOL) in men with PCa. Methods: Thirty-seven men with PCa about to undergo ADT with leuprolide acetate (ADT group) were followed prospectively for six months to evaluate changes in clinical and experimental pain. Forty men who had previously undergone prostatectomy for localized PCa and were in remission served as controls (non- ADT group). All participants were eugonadal at study entry. Primary outcomes were changes in clinical pain (assessed with Brief Pain Inventory questionnaire) and experimental pain (assessed with quantitative sensory testing). Secondary outcomes included evaluation of depression, anxiety levels, and quality of life. Results: Serum testosterone levels significantly decreased in the ADT group but remained unchanged in the non-ADT group. There were no significant changes in pain thresholds, ratings, or other responses to quantitative sensory tests over the 6-month course of the study. Clinical pain did not differ between the two groups, and no changes from baseline were observed in either group. Men undergoing ADT did experience worsening of depression (0.93; 95% CI = 0.04-1.82; P = 0.042) and QOL related to physical role limitation (-18.28; 95% CI = -30.18 to -6.37; P = 0.003). Conclusion: ADT in men with PCa is associated with worsening of depression scores and QOL but is not associated with changes in clinical pain or pain sensitivity.Copyright © 2017 American Academy of Hospice and Palliative Medicine Database: EMBASE

59. Which Seems to Be Worst Pain Severity and Quality of Life between Patients with Lateral Hip Pain and Low Back Pain Author(s): Ferrer-Pena R.; Calvo-Lobo C.; Aiguade R.; Fernandez-Carnero J. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article PubMedID: 30425756 Available at Pain research & management - from Europe PubMed Central - Open Access Available at Pain research & management - from Hindawi Open Access Journals Available at Pain research & management - from Pubmed Central - Open Access Abstract:Purpose. The aim of this study was to compare the pain severity, health-related quality of life (HRQoL), and risk of continue having pain with prognostic risk scores (PRS), between patients referring greater trochanteric pain syndrome (GTPS) and chronic low back pain (CLBP). Methods. A descriptive, cross-sectional design using nonprobability convenience sampling was performed. A total sample of 102 patients were recruited from two primary health-care centers and divided into GTPS (n = 51) and CLBP (n = 51) groups. The primary outcome was pain severity which was assessed with the Spanish version of the Graded Chronic Pain Scale (GCPS). The secondary outcome was the HRQoL which was measured using the Spanish version of EuroQoL Five Dimensions and Five Levels (EQ-5D-5L) as well as the PRS. Results. Significant differences (P<0.05) were found within both groups in the pain severity global score with a medium effect size showing greater values for the CLBP group with regards to the GTPS group. The PRS in both groups did not show statistical differences (P>0.05). Nevertheless, subjects referring CLBP showed greater levels in the PRS than patients with GTPS. Comparing both groups, the HRQoL showed statistical differences (P<0.05) in the "pain/discomfort" domain in the CLBP group with respect to the GTPS group, but not in the other domains. Conclusions. Patients who suffered from CLBP showed greater pain severity and HRQoL discomfort with regard to patients with GTPS. Despite greater scores for CLBP, the PRS did not seem to be different between both conditions.Copyright © 2018 Raul Ferrer-Pena et al. Database: EMBASE

60. Is abnormal glucose tolerance or diabetes a risk factor for knee, hip, or hand osteoarthritis? A systematic review Author(s): Dawson L.P.; Fairley J.L.; Papandony M.C.; Hussain S.M.; Cicuttini F.M.; Wluka A.E. Source: Seminars in Arthritis and Rheumatism; Oct 2018; vol. 48 (no. 2); p. 176-189 Publication Date: Oct 2018 Publication Type(s): Review PubMedID: 29550110 Abstract:Objective: Diabetes (DM) and osteoarthritis (OA) are two common co-existing chronic conditions. However, whether this is due to shared risk factors or may differ between joints is unclear. We performed a systematic review to determine whether abnormal glucose metabolism is a risk factor for knee, hip and hand OA, separately, independent of age and obesity. Methods: A systematic search of Ovid Medline and EMBASE was performed from inception until October 2016 to identify studies relating glucose metabolism to osteoarthritis-related outcomes. Studies were included if they related DM and OA and the knee, hip, or hand were examined separately. In the structured synthesis, objective measures of DM and adjustment for age and obesity were also required. Results: Of the 40 included studies, 28 examined the knee, nine the hip and 14 the hand. Five studies with a longitudinal component used objective measures of DM (blood glucose) and knee OA (radiography or joint replacement) and adjusted for age and obesity (21,299 participants). Of these, three found no association, one found a reduction in risk and one, which adjusted for the presence but not magnitude of obesity, found an increase in risk. Of the longitudinal studies examining the relationship between DM and OA that accounted for obesity, none provided evidence of an independent relationship between DM and hip (2 studies) or hand OA (1 study). Conclusion: There is little evidence to suggest that impaired glucose metabolism is a risk factor, independent of obesity, for knee OA and no evidence that impaired glucose metabolism is an independent risk factor for hip or hand OA.Copyright © 2018 Elsevier Inc. Database: EMBASE

61. Deep or awake removal of laryngeal mask airway in children at risk of respiratory adverse events undergoing tonsillectomy-a randomised controlled trial Author(s): Ramgolam A.; Hegarty M.; von Ungern-Sternberg B.S.; Hall G.L.; Zhang G. Source: British Journal of Anaesthesia; Mar 2018; vol. 120 (no. 3); p. 571-580 Publication Date: Mar 2018 Publication Type(s): Article Abstract:Background: Laryngeal mask airways (LMA) are widely used during tonsillectomies. Contrasting evidence exists regarding the timing of the removal and the risk of perioperative respiratory adverse events. We assessed whether the likelihood of perioperative respiratory adverse events is influenced by the timing of LMA removal in children with at least one risk factor for these events. Methods: Participants (n=290, 0-16 yr) were randomised to have their LMA removed either deep (in theatre by anaesthetist at end-tidal sevoflurane >1 minimum alveolar concentration) or awake (in theatre by anaesthetist or in postanaesthesia care unit by anaesthetist or trained nurse). The primary outcome was the occurrence of perioperative respiratory adverse events over the whole emergence and postanaesthesia care unit phases of anaesthesia. The secondary outcome was the occurrence of perioperative respiratory adverse events over the distinct phases of emergence and postanaesthesia care unit. Results: Data from 283 participants were analysed. Primary outcome: even though a higher occurrence of adverse events was observed in the awake group, no evidence for a difference was found [45% vs 35%, odds ratio (OR): 1.5, 95% confidence interval (CI): 0.9-2.5, P=0.09]. Secondary outcome: there was no evidence for a difference between the groups during emergence [19 (14%) deep vs 25 (18%) awake, OR: 0.74, 95%CI: 0.39-1.42, P=0.37]. However, in the postanaesthesia care unit, children with an awake rather than deep removal experienced significantly more adverse events [55 (39%) vs 37 (26%); OR: 1.85, 95%CI: 1.12-3.07, P=0.02]. Conclusion: We found no evidence for a difference in the timing of the LMA removal on the incidence of respiratory adverse events over the whole emergence and postanaesthesia care unit phases. However, in the postanaesthesia care unit solely, awake removal was associated with significantly more respiratory adverse events than deep removal. Trial registration number: ACTRN12609000387224 (www.anzctr.org.au).Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

62. Dexamethasone and postoperative hyperglycemia in diabetics undergoing elective hip or knee arthroplasty: A case control study in 238 patients Author(s): O'Connell R.S.; Golladay G.J.; Clinger B.N.; Donahue E.E.; Celi F.S. Source: Patient Safety in Surgery; Nov 2018; vol. 12 (no. 1) Publication Date: Nov 2018 Publication Type(s): Article Available at Patient Safety in Surgery - from ProQuest (Hospital Premium Collection) - NHS Version Available at Patient Safety in Surgery - from BioMed Central Available at Patient Safety in Surgery - from Europe PubMed Central - Open Access Available at Patient Safety in Surgery - from Pubmed Central - Open Access Abstract:Background: Dexamethasone has been routinely used in the pre-operative setting to enhance analgesia and decrease the incidence of nausea and vomiting in patients undergoing primary arthroplasty. However, dexamethasone has the potential to increase blood glucose levels postoperatively, which is a known risk factor for complications after total joint arthroplasty. The aim of this study was to analyze the effect of dexamethasone administration on post-operative blood glucose levels in diabetic patients after primary hip and knee arthroplasty. Methods: This study was a retrospective review of 238 diabetic patients who underwent primary hip and knee arthroplasty between May 1, 2014 and September 30, 2016 at a single urban academic medical center. A total of 77 patients (32.4%) received dexamethasone and 161 (67.7%) did not. Oral hyperglycemic agents were held during the inpatient stay and blood glucose was controlled either with sliding scale insulin or home insulin regimens were continued. All analyses were adjusted for age, BMI, gender, type of diabetes, pre-operative diabetic medication, type of surgical procedure, and pre-operative HgbA1c level. The primary outcome was post-operative hyperglycemia within 72 h of surgery defined as any blood glucose level greater than or equal to 200 mg/dL. Results: Post-operative hyperglycemia was observed in 17.1 and 20.6% of the measurements during the first 24 and 72 h respectively. After controlling for confounding variables, patients who received dexamethasone had 4.07 (95% CI: 2.46, 6.72) and 3.08 (95% CI: 2.34, 4.04) higher odds of post-operative hyperglycemia in the first 24 and 72 h respectively. Conclusions: Dexamethasone administration in diabetic patients undergoing primary arthroplasty increases post-operative hyperglycemia during the first 24 and 72 h. While our data did not investigate causation, dexamethasone use in this patient population should be thoughtfully considered, as post-operative hyperglycemia is a known risk factor for complications.Copyright © 2018 The Author(s). Database: EMBASE

63. The Effect of Combination Pharmacotherapy on Low Back Pain Author(s): Song L.; Qiu P.; Xu J.; Lv J.; Wang S.; Xia C.; Chen P.; Fan S.; Fang X.; Lin X. Source: Clinical Journal of Pain; Nov 2018; vol. 34 (no. 11); p. 1039-1046 Publication Date: Nov 2018 Publication Type(s): Review PubMedID: 29727303 Abstract:Objective: To evaluate the difference between combination pharmacotherapy and monotherapy on low back pain (LBP). Methods: We searched PubMed, Embase, and Cochrane Central Register of Controlled Trials databases up to March 14, 2017. Two authors independently extracted the data and assessed the validity of included trials. Results: Twelve randomized controlled trials comparing the effect of LBP combination pharmacotherapy to monotherapy or placebo were included. In chronic LBP, combination pharmacotherapy was more effective than placebo in pain relief (P<0.001; standardized mean difference [SMD], -0.50; 95% confidence interval [CI], -0.70 to -0.29; I2=0%) and function improvement (P<0.001; SMD, -0.27; 95% CI, -0.41 to -0.13; I2=0%) and showed improved pain relief compared with monotherapy (P<0.001; SMD, -0.84; 95% CI, -1.12 to - 0.56; I2=0%). Combination pharmacotherapy did not outperform monotherapy pain relief and function improvement in acute LBP. In addition, risk of adverse effects of combination pharmacotherapy was much higher compared with placebo (P<0.05; relative risk, 1.80; 95% CI, 1.33-2.42; I2>50%) and monotherapy (P<0.05; relative risk, 1.44; 95% CI, 1.01-2.06; I2>50%) in both settings. Discussion: Combination pharmacotherapy is more effective than placebo or monotherapy in the management of pain and disability in chronic LBP, but not in acute LBP. Further, combination pharmacotherapy has a higher risk of adverse effects than placebo and monotherapy.Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Database: EMBASE

64. IV maintenance fluids at McMaster children's hospital: A survey of physicians Author(s): Almehrezi S.; Duffet M.; Choong K. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: There are multiple controversies regarding fluid management in pediatrics, such as the ideal maintenance fluids, crystalloids vs colloids for volume expansion, and what appropriate volume of fluids to administer. In addition, awareness of the incidence of hyperchloremia and its associated morbidities is rising. Objective(s): To describe physicians' stated practices and preferences regarding IV fluids in hospitalized children, specifically with respect to: preferred solutions for maintenance and volume expansion, volume of administration, and frequency of monitoring as well as their knowledge of IV fluid composition. Method(s): Self-administered electronic survey, to trainee and attending physicians at McMaster Children's Hospital. We generated items according to domains of interest, and pre-tested the survey. Surveys were emailed with up to 2 reminders, from May and July 2016. Preliminary Results: 140 physicians responded: 53 (52%) staff, 11 (11%) fellows and 38 (37%) residents. The majority of respondents prefer isotonic maintenance fluids for all age groups: infants (77%), preschoolers (86%), children (89%) and adolescents (91%). However, some clinicians prefer hypotonic solutions particularly in for infants (16% of respondents) and preschoolers (12%). With respect to additives, 78% respondents routinely prescribe potassium dextrose is not routinely prescribed in adolescents in 31% respondents. Respondents monitored serum electrolytes once daily or less frequently 38% in patients receiving IV fluids. Respondents typically were aware of the sodium content of 0.9% NaCl solutions (88% correct responses), while 53% correctly reported the sodium content of Ringer's Lactate (RL). Respondents were less aware of chloride content (66% and 36% correct responses for 0.9% NaCl and RL respectively). Respondents were generally unaware of the sodium and chloride content of other solutions (5-11% correct responses for plasmalyte, 5% Albumin). Regarding volume expansion, 0.9%NaCl is the preferred solution in 85% respondents, followed by RL (14%). In a septic shock scenario, 24% and 69% would consider starting inotropes after 40 mL/kg and 60 mL/kg respectively, of volume expansion. Conclusion(s): Isotonic solutions are now the preferred maintenance solution. Clinicians do not have good knowledge of electrolyte content of commonly prescribed fluids beyond 0.9%NaCl. There may be a shift in practice towards a more conservative approach to volume expansion prior to inotropes. Database: EMBASE

65. ICU delirium, clinical outcomes and cost: Systematic review & meta-analysis Author(s): Kyeremanteng K.; Bhardwaj K.; Chaudhuri D.; Herritt B.; Lawlor P.; Bush S.; Kanji S.; Tanuseputro P.; Rosenberg E. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Objectives: To investigate the association between delirium and duration of mechanical ventilation in patients with delirium. The primary outcome is Intensive Care Unit Length of Stay (ICU LOS). The secondary outcomes are hospital LOS, an association between delirium and mortality in the ICU or the hospital and costeffectiveness. Design(s): Systematic review and meta-analysis of published studies. Update on previous systematic review and meta-analysis by Salluh et al. 2015. Data sources: PubMed, Embase, CINAHL, Cochrane Library, and PsychINFO, without language criteria, up to October 2016. Eligibility criteria for selection studies: The additional studies were included from January 2015 to October 2016, where patients were adults only and were evaluated for delirium with a validated screening or diagnostic instrument. The included studies reported the ICU LOS. Two reviewers independently screened citations, reviewed studies, abstracted data, and resolved disagreements by consensus. Only prospective observational cohorts or clinical trials of adults were assessed for quality. Result(s): Delirious patients had significantly higher mortality during (overall risk ratio 2.55, 82.67% confidence interval 1.94 to 3.35 P<0.001). Patients with delirium also reported longer hospital LOS and ICU LOS. The overall hospital LOS standard mean difference for overall studies is 1.07, 97.85% confidence interval 0.70 to 1.43; P<0.001. The overall ICU LOS mean difference is 4.93, 98.3% confidence interval 3.98 to 5.88 P<0.001. As per this updated review and meta-analysis, there is an association between delirium and ICU LOS and hospital LOS which ultimately leads to increase in cost. The cost analysis of recent studies showed that the cost of ICU stay is 40.8% and hospital stay is 41.4% more in delirious patients. Sensitivity analysis looking at recent studies and high quality papers, showed consistent results. Conclusion(s): Delirium results in increased risk of mortality, long length of stays in hospital and long length of stays in ICUs. In delirium patients, the mortality rate, hospital LOS, and ICU LOS are associated with an increase in cost. Database: EMBASE

66. Emergency department nurses' knowledge and experience with the new sepsis-3 criteria: A survey Author(s): Topcagic E.; Clayton N.; Cornell K.; McDonald E.; Fox-Robichaud A.; Welsford M.; Faidi W. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Sepsis is challenging to identify, particularly in those patients that present in the early stages of infection (early presenters). Early recognition reduces the time to treatment, which ultimately saves lives. In 2016, new Sepsis-3 criteria, specifically qSOFA (quick Sepsis-related Organ Failure Assessment) were identified. It is unknown how frontline Registered Nurses (RNs) working in the Emergency Department (ED) are operationalizing these new criteria. Objective(s): We sought to understand how RNs in the ED use the new Sepsis-3 criteria and their clinical experience to identify patients with suspected infection or sepsis, requiring timely treatment. Method(s): To understand RNs' operationalization of sepsis, including the new Sepsis-3 criteria, a 7-item survey was developed and distributed to all RNs at the Hamilton General Hospital an urban tertiary-care ED. During phase 1 the questionnaire was piloted with a convenience sample of 7 RNs in which feedback was obtained on sentence structure to 6 questions. Phase 2 tested for clinical sensibility of the questionnaire, a convenience sample of 7 respondents provided feedback using a 5-point Likert scale. The clinical sensibility testing covered several domains: appropriateness, redundancy, and survey completion time. We invited feedback on education around the new Sepsis-3 criteria and preferred learning strategy. Phase 3 included distribution of the final survey using paper versions and electronically via SurveyMonkey. Respondents were asked to provide demographic data: sex, education, and clinical experience. Result(s): The survey was distributed to 79 ED RNs, of which 50 (63%) completed the survey. The average time to completion was 3.8 minutes. Respondents identified hypotension (64.0%), heart rate (58.0%), and temperature (54.0%) as the best characteristics to identify patients with suspected sepsis. Using a Likert scale, 48 (96%) respondents scored an average of 4.3 out of 5 for their level of confidence with early recognition of patients with sepsis. Despite the new Sepsis-3 criteria published 1 year ago, 33 (66.0%) respondents were not familiar with qSOFA, 13 (26.0%) were aware it existed but had not been educated on it, 4 (8.0%) were familiar with the criteria but relied on other variables to identify septic patients, and none claimed to have thorough understanding of the qSOFA criterion for sepsis. The majority (82%) of respondents agreed that the Sepsis-3 criteria is effective in identifying patients with potential sepsis, and a medical directive should be available for RNs to identify and initiate treatment of septic patients or those at risk. Conclusion(s): We have identified a knowledge gap in nursing understanding of the new Sepsis-3 criteria. In this cohort of ED nurses, hypotension was identified as the number one indicator for sepsis patients, thus matching 1 of the 3-qSOFA criteria. Respondents identified an interest in learning about Sepsis-3 and qSOFA via a variety of educational modes. Furthermore, ED nurses support the use of a medical directive in suspected septic patients. A larger study of Emergency Department nurses to yield further information and impact on practice is recommended. Database: EMBASE

67. The epidemiology of infections and sepsis in the prehospital setting Author(s): Lane Daniel J.; Laurie M.; Hannah W.; Steve L.; Refik S.; Scales Damon C.; Sheldon C.; Blanchard Ian E.; Gerald L.; Christopher O. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Sepsis is a life-threatening syndrome caused by a dysregulated immune response to infection(1). Early recognition and intervention are critical to improve patient outcomes(2). In modern healthcare systems, paramedics often encounter patients with sepsis before other clinicians, offering an important opportunity for even earlier sepsis care(3). Objective(s): We sought to estimate the incidence and examine clinical and operational characteristics of patients with infection or sepsis who are transported by paramedics in a Canadian Emergency Medical Services (EMS) system. Method(s): A one-year cohort of all EMS transport events in the province of Alberta, Canada was linked to in- hospital administrative databases. Infection and sepsis were identified using administrative Emergency Department (ED) diagnosis codes and EMS clinical information, consistent with recommendations from the Sepsis-3 definition(1). Clinical characteristics (e.g. age, sex, vital signs), operational factors (e.g. prehospital encounter time), and treatments provided by paramedics (e.g. intravenous[IV] fluid treatment) were evaluated in patients with infection or sepsis, and compared to those of other patients transported by paramedics. Result(s): The incidence of infections (10%) and sepsis (2.1%) are notable within the paramedic- transported adult patient population, with more than half (56%) of these patients requiring admission to hospital. Fever (greater than 37.8 C) on presentation to paramedics was somewhat uncommon among patients with infections (17%), however, altered mental status (24.6%) and tachypnea (greater than 22 breaths per minute 31.6%) were more common. Compared to other patients transported by paramedics, patients with sepsis were generally older (mean 75 vs. 60 years), female (56.4%) and more frequently had altered vital signs, most commonly altered Glasgow Coma Score (less than 15 61%), tachypnea (48%), low oxygen saturation (less than 90% 34%), or fever (24.5%). Patients with sepsis were more likely to have a high priority dispatch (38% vs. 31%), but also had longer prehospital intervals (mean 44 min vs. 39 min, p<0.001) despite shorter transport distances (mean 15 km vs. 16 km, p=0.004). IV lines were initiated in 55% of septic patients compared to 34% of non-septic patients. In septic patients with a systolic blood pressure less than 100 mmHg, 70% received an IV but only 26% of those patients received at least 500 mL of fluid before arriving in the ED. The in-hospital mortality rate for paramedic-transported patients with infection or sepsis was 6.6% and 19%, respectively. Conclusion(s): Infections and sepsis are common among paramedic-transported patients, and paramedics spend a considerable time with these patients prior to arriving in the ED. These patients frequently have altered vital signs, suggesting earlier recognition is feasible. The in-hospital mortality of these patients is high, supporting the need to study earlier interventions provided in the prehospital setting. Database: EMBASE

68. The effect of cerebral perfusion pressure guided therapy on acute respiratory distress syndrome in traumatic brain injury Author(s): Thiara S.; Griesdale D.E.; Sekhon M.S.; Henderson W.R. Source: Canadian Journal of Anesthesia; Sep 2018; vol. 65 Publication Date: Sep 2018 Publication Type(s): Conference Abstract Abstract:Introduction: Previously, increased cerebral perfusion pressure (CPP) > 70mmHg has been associated with the onset of acute respiratory distress (ARDS) after traumatic brain injury (TBI). Recently, the concept of individualized perfusion targets using real time autoregulation assessment has emerged and at times, requires CPP titration > 70mmHg. Given historical concerns with increased incidence of ARDS, the association between ARDS and increased CPP requires further research. Objective(s): To investigate the relationship between increased cerebral perfusion pressure in traumatic brain injury patients who develop acute respiratory distress syndrome versus those who do not. Method(s): We conducted a single center retrospective cohort study investigating the association of increased CPP in patients who developed ARDS versus those who did not. We collected demographic data pertaining to age, gender, GCS motor score, Rotterdam CT score and mechanism of injury. We also collected physiologic data for CPP, intracranial pressure, ventilation parameters, cumulative fluid balance and delta pressure. Finally, we collected outcomes measures pertaining to duration of ventilation, length of ICU admission, length of hospitalzation and six month neurological outcome. Result(s): We conducted a retrospective analysis of 113 patients with severe TBI who underwent multimodal neuromonitoring. The mean age was 39 years (SD 17) and 26 / 113 (23%) were female gender. The median motor score was 3 (IQR 1 - 4). The median Rotterdam score was 3 (IQR 3 - 4). Sixteen patients (14%) developed ARDS according to the Berlin definition. There was no difference in the mean CPP during the first 7 days of admission between patients who developed ARDS (74mmHg SD 18 vs. 73mmHg SD 18, p=0.86) versus those who did not. There were no differences with respect to duration of mechanical ventilation, ICU length of stay, hospitalization or neurological outcome in both groups. Conclusion(s): In our cohort of severe TBI patients who underwent invasive neuromonitoring, we did not observe an association between increased CPP in patients who developed ARDS versus those who did not. (Table Presented) . Database: EMBASE

69. Thoracoscopic and Ultrasound Guidance for Optimization of Medication Spread during Thoracic Paravertebral Nerve Blockade Author(s): Visoiu M.; Scholz S. Source: Anesthesiology; Dec 2018; vol. 129 (no. 6); p. 1167-1168 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 30142090 Database: EMBASE

70. SponTaneous Respiration using IntraVEnous anaesthesia and Hi-flow nasal oxygen (STRIVE Hi) maintains oxygenation and airway patency during management of the obstructed airway: an observational study Author(s): Booth A.W.G.; Vidhani K.; Lee P.K.; Thomsett C.-M. Source: British journal of anaesthesia; Mar 2017; vol. 118 (no. 3); p. 444-451 Publication Date: Mar 2017 Publication Type(s): Article PubMedID: 28203745 Available at British Journal of Anaesthesia - from Unpaywall Abstract:Background: High-flow nasal oxygen (HFNO) has been shown to benefit oxygenation, ventilation and upper airway patency in a range of clinical scenarios, however its use in spontaneously breathing patients during general anaesthesia has not been described. Spontaneous respiration using i.v. anaesthesia is the primary technique used at our institution for tubeless airway surgery. We hypothesized that the addition of HFNO would increase our margin of safety, particularly during management of an obstructed airway. Method(s): A retrospective observational study was conducted using a SponTaneous Respiration using IntraVEnous anaesthesia and High-flow nasal oxygen (STRIVE Hi) technique to manage 30 adult patients undergoing elective laryngotracheal surgery. Result(s): Twenty-six patients (87%) presented with significant airway and/or respiratory compromise (16 were stridulous, 10 were dyspnoeic). No episodes of apnoea or complete airway obstruction occurred during the induction of anaesthesia using STRIVE Hi. The median [IQR (range)] lowest oxygen saturation during the induction period was 100 [99-100 (97-100)] %. The median [IQR (range)] overall duration of spontaneous ventilation was 44 [40-49.5 (18-100)] min. The median [IQR (range)] end-tidal carbon dioxide (ETCO2) level at the end of the spontaneous ventilation period was 6.8 [6.4-7.1 (4.8-8.9)] kPa. The mean rate of increase in ETCO2 was 0.03kPa min-1. Conclusion(s): STRIVE Hi succeeded in preserving adequate oxygen saturation, end-tidal carbon dioxide and airway patency. We suggest that the upper and lower airway benefits attributed to HFNO, are ideally suited to a spontaneous respiration induction, increasing its margin of safety. STRIVE Hi is a modern alternative to the traditional inhalation induction.Copyright © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. Database: EMBASE

71. Risk prediction models for delirium in the intensive care unit after cardiac surgery: a systematic review and independent external validation Author(s): Lee A.; Mu J.L.; Joynt G.M.; Chiu C.H.; Lai V.K.W.; Gin T.; Underwood M.J. Source: British journal of anaesthesia; Mar 2017; vol. 118 (no. 3); p. 391-399 Publication Date: Mar 2017 Publication Type(s): Article PubMedID: 28186224 Abstract:Numerous risk prediction models are available for predicting delirium after cardiac surgery, but few have been directly compared with one another or been validated in an independent data set. We conducted a systematic review to identify validated risk prediction models of delirium (using the Confusion Assessment Method-Intensive Care Unit tool) after cardiac surgery and assessed the transportability of the risk prediction models on a prospective cohort of 600 consecutive patients undergoing cardiac surgery at a university hospital in Hong Kong from July 2013 to July 2015. The discrimination (c-statistic), calibration (GiViTI calibration belt), and clinical usefulness (decision curve analysis) of the risk prediction models were examined in a stepwise manner. Three published high-quality intensive care unit delirium risk prediction models (n=5939) were identified: Katznelson, the original PRE-DELIRIC, and the international recalibrated PRE-DELIRIC model. Delirium occurred in 83 patients (13.8%, 95% CI: 11.2-16.9%). After updating the intercept and regression coefficients in the Katznelson model, there was fair discrimination (0.62, 95% CI: 0.58-0.66) and good calibration. As the original PRE-DELIRIC model was already validated externally and recalibrated in six countries, we performed a logistic calibration on the recalibrated model and found acceptable discrimination (0.75, 95% CI: 0.72-0.79) and good calibration. Decision curve analysis demonstrated that the recalibrated PRE-DELIRIC risk model was marginally more clinically useful than the Katznelson model. Current models predict delirium risk in the intensive care unit after cardiac surgery with only fair to moderate accuracy and are insufficient for routine clinical use.Copyright © The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: [email protected]. Database: EMBASE

72. Emergency cricothyroidotomy: an observational study to estimate optimal incision position and length Author(s): Fennessy P.; Husarova V.; McCaul C.L.; Drew T.; Duggan M. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: A vertical incision is recommended for cricothyroidotomy when the anatomy is impalpable, but no evidence-based guideline exists regarding optimum site or length. The Difficult Airway Society guidelines, which are based on expert opinion, recommend an 80-100 mm vertical caudad to cephalad incision in the extended neck position. However, the guidelines do not advise the incision commencement point. We sought to determine the minimum incision length and commencement point above the suprasternal notch required to ensure that the cricothyroid membrane would be accessible within its margins. Method(s): We measured using ultrasound, in 80 subjects (40 males and 40 females) without airway pathology, the distance between the suprasternal notch and the cricothyroid membrane, in the neutral and extended neck positions. We assessed the inclusion of the cricothyroid membrane within theoretical incisions of 0-100 mm in length made at 10 mm intervals above the suprasternal notch. Result(s): In 80 subjects (40 males and 40 females), the distance ranged from 27 to 105 mm. Movement of the cricothyroid membrane on transition from the neutral to extended neck position varied from 15 mm caudad to 27 mm cephalad. The minimum incision required in the extended position was 70 mm in males and 80 mm in females, commencing 30 mm above the suprasternal notch. Conclusion(s): An 80 mm incision commencing 30 mm above the suprasternal notch would include all cricothyroid membrane locations in the extended position in patients without airway pathology, which is in keeping with the Difficult Airway Society guidelines recommended incision length.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

73. Efficacy of a new dual channel laryngeal mask airway, the LMAGastroTM Airway, for upper gastrointestinal endoscopy: a prospective observational study Author(s): Terblanche N.C.S.; Skinner M.; Middleton C.; Choi-Lundberg D.L. Source: British Journal of Anaesthesia; Feb 2018; vol. 120 (no. 2); p. 353-360 Publication Date: Feb 2018 Publication Type(s): Article Abstract:Background: Significant cardiorespiratory events are frequent in patients undergoing gastrointestinal endoscopy. Central to the occurrence of respiratory events is an unsecured airway. This study sought to determine the efficacy of a new laryngeal mask airway, the LMAGastroTM Airway (Teleflex Medical, Athlone, Ireland), in patients undergoing upper gastrointestinal endoscopy. New design features include a dedicated channel for oesophageal intubation and separate channel with terminal cuff for lung ventilation. Methods: In a prospective, open label, observational study, 292 ASA physical status classification 1 and 2 patients at low risk of pulmonary aspiration undergoing upper gastrointestinal endoscopy received i.v. propofol anaesthesia and standardized insertion of the LMAGastroTM Airway. Endoscopy outcomes included insertion success, first attempt success, and ease of endoscope insertion. LMAGastroTM Airway outcomes included insertion success, first attempt success, ease of insertion, lowest oxygen saturation, airway compromise, laryngospasm, bloodstained device, and sore throat. Results: Per protocol analysis (n=290), the endoscopy success rate amongst the cohort with successful LMAGastroTM Airway insertion was 99% [95% confidence interval (CI): 98, 100]. LMAGastroTM Airway insertion success rate (n=292) was 99% (95% CI: 98, 100). For endoscopy and LMAGastroTM Airway insertion success, the lower limit of the 95% CIs was at least 98%, indicating LMAGastroTM Airway efficacy. Median (inter-quartile range) lowest intraoperative oxygen saturation was 98% (98, 99). Only one serious adverse event occurred (re-admission for sore throat and inability to tolerate fluids) and was reported to the Tasmanian Health and Medical Human Research Ethics Committee. Conclusions: The LMAGastroTM Airway appears effective for clinical use in upper gastrointestinal endoscopy. Clinical trial registration: ACTRN12616001464459.Copyright © 2017 British Journal of Anaesthesia Database: EMBASE

74. Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation Author(s): Levett D.Z.H.; Jack S.; Grocott M.P.W.; Swart M.; Carlisle J.; Wilson J.; Snowden C.; Riley M.; Danjoux G.; Ward S.A.; Older P. Source: British Journal of Anaesthesia; Mar 2018; vol. 120 (no. 3); p. 484-500 Publication Date: Mar 2018 Publication Type(s): Article Abstract:The use of perioperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative events and inform the perioperative management of patients undergoing surgery has increased over the last decade. CPET provides an objective assessment of exercise capacity preoperatively and identifies the causes of exercise limitation. This information may be used to assist clinicians and patients in decisions about the most appropriate surgical and non-surgical management during the perioperative period. Information gained from CPET can be used to estimate the likelihood of perioperative morbidity and mortality, to inform the processes of multidisciplinary collaborative decision making and consent, to triage patients for perioperative care (ward vs critical care), to direct preoperative interventions and optimization, to identify new comorbidities, to evaluate the effects of neoadjuvant cancer therapies, to guide prehabilitation and rehabilitation, and to guide intraoperative anaesthetic practice. With the rapid uptake of CPET, standardization is key to ensure valid, reproducible results that can inform clinical decision making. Recently, an international Perioperative Exercise Testing and Training Society has been established (POETTS www.poetts.co.uk) promoting the highest standards of care for patients undergoing exercise testing, training, or both in the perioperative setting. These clinical cardiopulmonary exercise testing guidelines have been developed by consensus by the Perioperative Exercise Testing and Training Society after systematic literature review. The guidelines have been endorsed by the Association of Respiratory Technology and Physiology (ARTP).Copyright © 2017 Database: EMBASE

75. Preexisting Right Ventricular Dysfunction Is Associated With Higher Postoperative Cardiac Complications and Longer Hospital Stay in High-Risk Patients Undergoing Nonemergent Major Vascular Surgery Author(s): Chou J.; Ma M.; Gylys M.; Seong J.; Salvatierra N.; Kim R.; Rinehart J.; Jiang L.; Barseghian A. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Objectives: To evaluate whether the presence of preexisting right ventricular (RV) dysfunction in high-risk patients undergoing nonemergent major vascular surgery is associated independently with higher incidents of postoperative cardiac complications and a longer length of hospital stay. Design(s): Retrospective chart review. Setting(s): Single-center university hospital setting. Participant(s): The patient population consisted of those identified as American Society of Anesthesiologists classification III and above who had a preoperative echocardiogram within 1 year of undergoing nonemergent major vascular surgery between January 2010 and May 2017. Measurements and Main Results: After multivariate analyses, RV dysfunction (RVD) is associated independently with a higher incidence of postoperative major cardiac complications with an odds ratio = 6.3 (95% confidence interval [CI], 1.0-38.5; p = 0.046). In addition, patients with RVD had a 50% longer length of stay than those without RVD (incident rate ratio [95% CI], 1.5 [1.2-1.8]; p < 0.001). Conclusion(s): In this retrospective study of high-risk patients undergoing major vascular surgery, RV dysfunction was associated independently with a higher incidence of postoperative major cardiovascular events and longer length of hospital stays. Based on current findings, the prognostic value of RVD extends beyond the cardiac surgical cohort. Knowledge in management of patients with RVD in the perioperative setting should be understood by all anesthesiologists. Of note, a future study with a larger sample size is needed to validate the current findings given the small sample size of this study.Copyright © 2018 Database: EMBASE

76. Is a Retrolaminar Approach to the Thoracic Paravertebral Space Possible?: A Human Cadaveric Study Author(s): Sassan Sabouri A.; Nozari A.; Crawford L.; Bick S.K.; Anderson T.A. Source: Regional Anesthesia and Pain Medicine; Nov 2018; vol. 43 (no. 8); p. 864-868 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29923954 Abstract:Background and Objectives The retrolaminar block (RB) is used for truncal analgesia, but its mechanism of neural blockade remains obscure. We sought to learn the pattern of local anesthetic spread after thoracic RB using cadaveric models. Methods In 8 fresh cadavers, an ultrasound-guided T4 RB was performed with 20 mL of methylene blue 1% and bupivacaine 0.5%. For comparison, an RB at T9 in 1 cadaver and a T4 thoracic paravertebral block in another cadaver were performed. Subsequently, posterior and anterior thoracic dissections were performed to examination where the dye spread. Results After T4 RB, dye was noted to spread in the ipsilateral retrolaminar plane (all 8 cadavers, median cephalad spread 3.5 cm, caudad spread 10.7 cm, lateral spread 2.5 cm), the contralateral retrolaminar plane (6 cadavers), the paravertebral space (5 cadavers, median of 3 segments, T3-T5), the intercostal space (5 cadavers, median of 3.5 cm laterally), the T4 epidural space (6 cadavers), and the intervertebral foramina (4 cadavers, median of 2 segments, T4-T5). After T9 retrolaminar injection, dye was noted in the ipsilateral retrolaminar plane (5.5 cm cephalad, 13.5 cm caudad, and 2.5 cm lateral), the contralateral retrolaminar plane, and the epidural space. Dye after T4 traditional paravertebral block spread to T1-T6 paravertebral space with 15-cm lateral spread. Conclusions Injectate spread to the paravertebral space, epidural space, intercostal space, and intervertebral foramina is possible in the RB but is quite variable. In comparison to the thoracic paravertebral block, injectate spread within the paravertebral space is more limited.Copyright © 2018 Lippincott Williams & Wilkins. Database: EMBASE

77. Pericapsular Nerve Group (PENG) Block for Hip Fracture Author(s): Giron-Arango L.; Peng P.W.H.; Chin K.J.; Brull R.; Perlas A. Source: Regional Anesthesia and Pain Medicine; Nov 2018; vol. 43 (no. 8); p. 859-863 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30063657 Abstract:Fascia iliaca block or femoral nerve block is used frequently in hip fracture patients because of their opioid-sparing effects and reduction in opioid-related adverse effects. A recent anatomical study on hip innervation led to the identification of relevant landmarks to target the hip articular branches of femoral nerve and accessory obturator nerve. Using this information, we developed a novel ultrasound-guided approach for blockade of these articular branches to the hip, the PENG (PEricapsular Nerve Group) block. In this report, we describe the technique and its application in 5 consecutive patients.Copyright © 2018 Lippincott Williams & Wilkins. Database: EMBASE

78. Serratus Plane Block: A Cadaveric Study to Evaluate Optimal Injectate Spread Author(s): Biswas A.; Castanov V.; Li Z.; Agur A.; Perlas A.; Kruisselbrink R.; Chan V. Source: Regional Anesthesia and Pain Medicine; Nov 2018; vol. 43 (no. 8); p. 854-858 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30063656 Abstract:Background and Objectives Although serratus plane block reportedly provides satisfactory analgesia for breast and thoracic surgeries, the optimal technique for consistent success has not been studied. The goal of this anatomical study was to evaluate the impact of volume, level, and site of injection on the extent of injectate spread that can influence anesthetic coverage. Methods Ultrasound-guided dye injection and subsequent dissection were performed in 39 cadaveric hemithoraces. Methylene blue was injected according to 1 of 4 injection protocols as follows: one 20-mL bolus, either superficial or deep to the serratus anterior muscle (SAM), at the fifth rib level (groups SUP-20 and DEEP-20, respectively), or two 20-mL boluses, either superior or deep to the SAM, one at the third rib and one at the fifth rib level (group SUP-40 and group DEEP-40, respectively). Following injection, dissection and 3-dimensional digitization were performed to map the area of dye spread. Results We found that the extent of dye spread was mostly influenced by the volume of injection rather than the plane of injection (superficial vs deep to SAM). Increasing the volume from 20 to 40 mL doubled the area of injectate spread and promoted dye spread preferentially to the anterior chest wall, with some impact on cephalad-to- caudad spread and no impact on posterior spread. Dye was found most consistently in the axilla when a separate injection was performed at the third rib level. Conclusions Our data showed that a high-volume double-injection technique provides extensive and consistent dye spread in the anterior chest wall and axilla, regardless of the plane of injection relative to the SAM. This technique likely provides more reliable analgesic coverage for breast procedures especially those that involve the axilla, pending confirmation in future clinical studies.Copyright © 2018 Lippincott Williams & Wilkins. Database: EMBASE

79. Lipid Emulsion Pretreatment Decreased the Maximum Total and Free Plasma Concentration of Levobupivacaine for Femoral and Sciatic Nerve Block in Below-Knee Fracture Surgery Author(s): Chen Y.; Zhang J.; Li B.; Lai R.; Cao Z.; Yu L.; Chen Z.; Wang Q.; Xu X. Source: Regional Anesthesia and Pain Medicine; Nov 2018; vol. 43 (no. 8); p. 838-843 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29923955 Abstract:Background and Objectives Although intravenous lipid emulsion has been proved a powerful antidote for local anesthetic toxicity, there are few pharmacokinetic data on using lipid infusion as a pretreatment for other clinical applications. We assessed the influence of lipid pretreatment on the pharmacodynamics and pharmacokinetics of levobupivacaine. Methods Altogether, 12 patients undergoing below-knee surgery for a fracture were randomly assigned to 2 groups (6 patients per group): pretreatment with 1.5 mL/kg lipid infusion (lipid group) or saline infusion (control subjects) followed by complete femoral and sciatic nerve block with 0.375% levobupivacaine (2.5 mg/kg). Total and free (non-protein bound) plasma levobupivacaine concentrations and triglycerides in the lipid group were determined. Results Results were given as means +/- SD. Total and free maximum plasma levobupivacaine concentrations were lower in the lipid group than in control subjects (865 +/- 98 vs 1145 +/- 177 mug/L and 56.8 +/- 7.5 vs 78.2 +/- 13.7 mug/L, respectively; P < 0.01). Apparent volume of distribution and clearance were higher in the lipid group than in control subjects (211 +/- 35 vs 170 +/- 21 L and 35.1 +/- 8.0 vs 25.8 +/- 2.6 L/h, respectively; P < 0.05). Triglyceride level was significantly higher at the end of lipid infusion than baseline values (7.59 +/- 1.32 vs 1.34 +/- 0.39 mmol/L; P < 0.01). Conclusions Lipid pretreatment increased the apparent volume of distribution and clearance and decreased the maximum total and free levobupivacaine concentrations, thus offering a reasonable explanation for the effects of lipids on local anesthesia-related toxicity in humans. Rapid lipid infusion induced hypertriglyceridemia without other apparent risks in this study. Clinical Trial Registration This study was registered at the Chinese Clinical Trial Registry, identifier ChiCTR-TRC-14005203.Copyright © 2018 Lippincott Williams & Wilkins. Database: EMBASE

80. Ultrasound-Guided Selective Versus Conventional Block of the Medial Brachial Cutaneous and the Intercostobrachial Nerves: A Randomized Clinical Trial Author(s): Magazzeni P.; Mekler G.; Bouaziz H.; Jochum D.; Iohom G.; Albuisson E. Source: Regional Anesthesia and Pain Medicine; Nov 2018; vol. 43 (no. 8); p. 832-837 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29905631 Abstract:Background and Objectives For superficial surgery of anteromedial and posteromedial surfaces of the upper arm, the medial brachial cutaneous nerve (MBCN) and the intercostobrachial nerve (ICBN) must be selectively blocked, in addition to an axillary brachial plexus block. We compared efficacy of ultrasound-guided (USG) versus conventional block of the MBCN and the ICBN. Methods Eighty-four patients, undergoing upper limb surgery, were randomized to receive either USG (n = 42) or conventional (n = 42) block of the MBCN and the ICBN with 1% mepivacaine. Sensory block was evaluated using light-touch on the upper and lower half of the anteromedial and posteromedial surfaces of the upper arm at 5, 10, 15, 20 minutes after nerve blocks. The primary outcome was the proportion of patients who had no sensation in all 4 regions innervated by the MBCN and the ICBN at 20 minutes. Secondary outcomes were onset time of complete anesthesia, volume of local anesthetic, tourniquet tolerance, and quality of ultrasound images. Results In the USG group, 37 patients (88%) had no sensation at 20 minutes in any of the 4 areas tested versus 8 patients (19%) in the conventional group (P < 0.001). When complete anesthesia was obtained, it occurred within 10 minutes in more than 90% of patients, in both groups. Mean total volumes of local anesthetic used for blocking the MBCN and the ICBN were similar in the 2 groups. Ultrasound images were of good quality in only 20 (47.6%) of 42 patients. Forty-one patients (97.6%) who received USG block were comfortable with the tourniquet versus 16 patients (38.1%) in the conventional group (P < 0.001). Conclusions Ultrasound guidance improved the efficacy of the MBCN and ICBN blocks. Clinical Trial Registration This study was registered at ClinicalTrials.gov, identifier NCT02940847.Copyright © 2018 Lippincott Williams & Wilkins. Database: EMBASE

81. Mindfulness for Chronic Low Back Pain: A Qualitative Analysis Author(s): Luiggi-Hernandez J.G.; Woo J.; Hamm M.; Morone N.E.; Greco C.M.; Weiner D.K. Source: Pain medicine (Malden, Mass.); Nov 2018; vol. 19 (no. 11); p. 2138-2145 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29025059 Abstract:Objective: Mindfulness is a nonpharmacologic mind-body therapy that has been shown to be effective in older adults with chronic low back pain (cLBP). There are few first- person accounts in the literature that describe the older adult experience and perspective while learning mindfulness and meditation to treat pain. The objective of this study was to investigate dominant themes present in the experiences of older adults applying mindfulness and meditation to cope with cLBP. Design: Qualitative analysis of four focus groups. Subject: Twenty-five adults age 65years or older who had completed an eight-week mindfulness program. Methods: The focus groups met for a comprehensive discussion session about their experience with mindfulness and meditation. The audio for each session was recorded, and the discussions were transcribed. Codebook development, qualitative coding, and thematic analysis were performed. The coders each coded all four transcripts, following which they met to adjudicate all coding differences until they were in complete agreement on coding. Results: Several key themes were brought up by older adults utilizing mindfulness as a means of coping with pain, which included overcoming fear of pain ("Before [learning mindfulness], I used to dread pain"), pain awareness ("You're focusing more on being aware than the pain; now that's what helps me"), and pain significance ("It becomes insignificant"). Conclusions: The themes identify several ways mindfulness impacts older adults with cLBP, including decreased negative emotions related to chronic pain such as fear of pain, a different perspective or change in awareness about pain, and reducing the significance of pain. Database: EMBASE

82. Re: Spinal Cord Stimulation (SCS) with Anatomically Guided (3D) Neural Targeting Shows Superior Chronic Axial Low Back Pain Relief Compared to Traditional SCS-LUMINA Study Author(s): Kapural L.; Verills P.; Amirdelfan K.; Falowski S.; van Buyten J.-P. Source: Pain medicine (Malden, Mass.); Nov 2018; vol. 19 (no. 11); p. 2324-2325 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29635289 Database: EMBASE

83. Guidelines for Composing and Assessing a Paper on the Treatment of Pain: A Practical Application of Evidence-Based Medicine Principles to the Mint Randomized Clinical Trials Author(s): McCormick Z.L.; Vorobeychik Y.; Gill J.S.; Kao M.-C.J.; Duszynski B.; Smuck M.; Stojanovic M.P. Source: Pain medicine (Malden, Mass.); Nov 2018; vol. 19 (no. 11); p. 2127-2137 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29579232 Abstract:Objective: To perform a thorough assessment of the recently published Mint Trials in order to illustrate how to read and analyze a study critically, according to principles of evidence-based medicine. Design: Narrative review. Method: We have applied the recently published guidelines for composing and assessing studies on the treatment of pain to a recently published article describing a large study that claimed its "findings do not support the use of radiofrequency denervation to treat chronic low back pain." These guidelines describe the critical components of a high-quality manuscript that allows communication of all relevant information from authors to readers. Results: Application of evidence-based medicine principles to the publication describing the Mint Trials reveals significant issues with the methodology and conclusions drawn by the authors. A thorough assessment demonstrates issues with inclusion/exclusion criteria, diagnostic block protocols, radiofrequency neurotomy technique, co-interventions, outcome measurement, power analysis, study sample characteristics, data analysis, and loss to follow-up. A failure to definitively establish a diagnosis, combined with use of an inadequate technique for radiofrequency neurotomy and numerous other methodological flaws, leaves the reader unable to draw meaningful conclusions from the study data. Conclusions: Critical analysis, rooted in principles of evidence-based medicine, must be employed by writers and readers alike in order to encourage transparency and ensure that appropriate conclusions are drawn from study data. Database: EMBASE

84. Sepsis in pregnancy and the puerperium Author(s): Burlinson C.E.G.; Chau A.; Sirounis D.; Walley K.R. Source: International Journal of Obstetric Anesthesia; Nov 2018; vol. 36 ; p. 96-107 Publication Date: Nov 2018 Publication Type(s): Review PubMedID: 29921485 Abstract:Sepsis remains a leading cause of maternal morbidity and mortality. Recognition and treatment of maternal sepsis are often delayed due to the physiological adaptations of pregnancy and vague or absent signs and symptoms during its initial presentation. Over the past decade, our understanding of sepsis has evolved and maternal early warning systems have been developed in an effort to help providers promptly identify and stratify parturients who are at risk. In addition, new consensus definitions and care bundles have recently been published by the World Health Organization and the Surviving Sepsis Campaign to facilitate earlier recognition and timely management of sepsis. In this narrative review, we summarize the available evidence about sepsis and provide an overview of the research efforts focused on maternal sepsis to date. Controversies and challenges surrounding the anesthetic management of parturients with sepsis or at risk of developing sepsis during pregnancy or the puerperium will be highlighted.Copyright © 2018 Elsevier Ltd Database: EMBASE

85. Diabetes Mellitus: Preoperative Concerns and Evaluation Author(s): Sreedharan R.; Abdelmalak B. Source: Anesthesiology Clinics; Dec 2018; vol. 36 (no. 4); p. 581-597 Publication Date: Dec 2018 Publication Type(s): Review PubMedID: 30390780 Abstract:Diabetes is an important cause of morbidity in the adult population resulting in blindness, renal dysfunction, cardiovascular events, and amputation. Such morbidities may have an impact on perioperative anesthetic care and outcomes. In this review, the authors discuss the preoperative considerations in managing patients with diabetes as well as those without diabetes albeit hyperglycemic. They propose a plan for managing preoperative diabetes pharmacotherapy, including the use of a subcutaneous insulin pump to avoid both hypoglycemia and hyperglycemia. The authors also discuss the decision whether to proceed or cancel surgery for a given hemoglobin A1c percentage or blood glucose concentration.Copyright © 2018 Elsevier Inc. Database: EMBASE

86. Brain Mechanisms of Anticipated Painful Movements and Their Modulation by Manual Therapy in Chronic Low Back Pain Author(s): Ellingsen D.-M.; Napadow V.; Protsenko E.; Mawla I.; Loggia M.L.; Kowalski M.H.; Swensen D.; O'Dwyer-Swensen D.; Edwards R.R.; Kettner N. Source: Journal of Pain; Nov 2018; vol. 19 (no. 11); p. 1352-1365 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 30392530 Abstract:Heightened anticipation and fear of movement-related pain has been linked to detrimental fear-avoidance behavior in chronic low back pain (cLBP). Spinal manipulative therapy (SMT) has been proposed to work partly by exposing patients to nonharmful but forceful mobilization of the painful joint, thereby disrupting the relationship among pain anticipation, fear, and movement. Here, we investigated the brain processes underpinning pain anticipation and fear of movement in cLBP, and their modulation by SMT, using functional magnetic resonance imaging. Fifteen cLBP patients and 16 healthy control (HC) subjects were scanned while observing and rating video clips depicting back-straining or neutral physical exercises, which they knew they would have to perform at the end of the visit. This task was repeated after a single session of spinal manipulation (cLBP and HC group) or mobilization (cLBP group only), in separate visits. Compared with HC subjects, cLBP patients reported higher expected pain and fear of performing the observed exercises. These ratings, along with clinical pain, were reduced by SMT. Moreover, cLBP, relative to HC subjects, demonstrated higher blood oxygen level-dependent signal in brain circuitry that has previously been implicated in salience, social cognition, and mentalizing, while observing back straining compared with neutral exercises. The engagement of this circuitry was reduced after SMT, and especially the spinal manipulation session, proportionally to the magnitude of SMT-induced reduction in anticipated pain and fear. This study sheds light on the brain processing of anticipated pain and fear of back-straining movement in cLBP, and suggests that SMT may reduce cognitive and affective-motivational aspects of fear- avoidance behavior, along with corresponding brain processes. Perspective: This study of cLBP patients investigated how SMT affects clinical pain, expected pain, and fear of physical exercises. The results indicate that one of the mechanisms of SMT may be to reduce pain expectancy, fear of movement, and associated brain responses.Copyright © 2018 the American Pain Society Database: EMBASE

87. Recruitment manoeuvres dislodge mucus towards the distal airways in an experimental model of severe pneumonia Author(s): Li Bassi G.; Marti D.; Xiol E.A.; Ranzani O.T.; Amaro R.; De Rosa F.; Rigol M.; Fernandez L.; Luque N.; Torres A.; Comaru T.; Chiurazzi C.; Travierso C.; Carbonara M.; Zanella A.; Blasi F.; Frigola G.; Fuster C.; Saco M.A.; Ramirez J.; Suen J.; Fraser J. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Recruitment manoeuvres (RM) generate a transient increase in trans- pulmonary pressure that could open collapsed alveoli. RM might generate very high inspiratory airflows. We evaluated whether RM could displace respiratory secretions towards the distal airways and impair gas exchange in a porcine model of bacterial pneumonia. Methods: We conducted a prospective randomised study in 10 mechanically ventilated pigs. Pneumonia was produced by direct intra-bronchial introduction of Pseudomonas aeruginosa. Four RM were applied randomly: extended sigh (ES), maximal recruitment strategy (MRS), sudden increase in driving pressure and PEEP (SI-PEEP), and sustained inflation (SI). Mucus transport was assessed by fluoroscopic tracking of radiopaque disks before and during each RM. The effects of each RM on gas exchange were assessed 15 min after the intervention. Results: Before RM, mucus always cleared towards the glottis. Conversely, mucus was displaced towards the distal airways in 28.6% ES applications and 50% of all other RMs (P=0.053). Median mucus velocity was 1.26 mm min-1 [0.48-3.89] before each RM, but was reversed (P=0.007) during ES [0.10 mm min-1 [-0.04- 1.00]], MRS [0.10 mm min-1 [-0.4-0.48]], SI-PEEP [0.02 mm min-1 [-0.14-0.34]], and SI [0.10 mm min-1 [-0.63-0.75]]. When PaO2 failed to improve after RM, mucus was displaced towards the distal airways in 68.7% of the cases, compared with 31.2% RM associated with improved PaO2 (odds ratio: 4.76 (95% confidence interval: 1.13-19.97). Conclusions: RM dislodge mucus distally, irrespective of airflow generated by different RM. Further investigation in humans is warranted to corroborate these pre clinical findings, as there may be limited benefits associated with lung recruitment in pneumonia.Copyright © 2018 Database: EMBASE

88. Identifying and Engaging Neuronal Oscillations by Transcranial Alternating Current Stimulation in Patients With Chronic Low Back Pain: A Randomized, Crossover, Double- Blind, Sham-Controlled Pilot Study Author(s): Ahn S.; Prim J.H.; Alexander M.L.; Frohlich F.; McCulloch K.L. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Chronic pain is associated with maladaptive reorganization of the central nervous system. Recent studies have suggested that disorganization of large-scale electrical brain activity patterns, such as neuronal network oscillations in the thalamocortical system, plays a key role in the pathophysiology of chronic pain. Yet, little is known about whether and how such network pathologies can be targeted with noninvasive brain stimulation as a nonpharmacological treatment option. We hypothesized that alpha oscillations, a prominent thalamocortical activity pattern in the human brain, are impaired in chronic pain and can be modulated with transcranial alternating current stimulation (tACS). We performed a randomized, crossover, double-blind, sham-controlled study in patients with chronic low back pain (CLBP) to investigate how alpha oscillations relate to pain symptoms for target identification and whether tACS can engage this target and thereby induce pain relief. We used high-density electroencephalography to measure alpha oscillations and found that the oscillation strength in the somatosensory region at baseline before stimulation was negatively correlated with pain symptoms. Stimulation with alpha-tACS compared to sham (placebo) stimulation significantly enhanced alpha oscillations in the somatosensory region. The stimulation-induced increase of alpha oscillations in the somatosensory region was correlated with pain relief. Given these findings of successful target identification and engagement, we propose that modulating alpha oscillations with tACS may represent a target-specific, nonpharmacological treatment approach for CLBP. This trial has been registered in ClinicalTrials.gov (NCT03243084). Perspective: This study suggests that a rational design of transcranial alternating current stimulation, which is target identification, engagement, and validation, could be a nonpharmacological treatment approach for patients with CLBP.Copyright © 2018 Database: EMBASE

89. Characteristics Associated With High-Impact Pain in People With Temporomandibular Disorder: A Cross-Sectional Study Author(s): Miller V.E.; Poole C.; Golightly Y.; Barrett D.; Chen D.-G.; Slade G.D.; Ohrbach R.; Greenspan J.D.; Fillingim R.B. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:High-impact (disabling) pain diminishes the quality of life and increases health care costs. The purpose of this study was to identify the variables that distinguish between high- and low-impact pain among individuals with painful temporomandibular disorder (TMD). Community-dwelling adults (N = 846) with chronic TMD completed standardized questionnaires that assessed the following: 1) sociodemographic characteristics, 2) psychological distress, 3) clinical pain, and 4) experimental pain. We used high-impact pain, classified using the Graded Chronic Pain Scale, as the dependent variable in logistic regression modeling to evaluate the contribution of variables from each domain. Cross- validated area under the receiver operating characteristic curve (AUC) quantified model discrimination. One-third of the participants had high-impact pain. Sociodemographic variables discriminated weakly between low- and high-impact pain (AUC =.61, 95% confidence interval [CI] = 0.57, 0.65), with the exception of race. An 18-variable model encompassing all 4 domains had good discrimination (AUC = 0.79, 95% CI = 0.75, 0.82), as did a simplified model (sociodemographic variables plus catastrophizing, jaw limitation, and number of painful body sites) (AUC = 0.79, 95% CI = 0.76, 0.82). Duration of pain, sex, and experimental pain testing results were not associated. The characteristics that discriminated most effectively between people with low- and high-impact TMD pain included clinical pain features and the ability to cope with pain. Perspective: This article presents the results of a multivariable model designed to discriminate between people with high- and low-impact pain in a community-based sample of people with painful chronic TMD. The findings emphasize the importance of catastrophizing, jaw limitation, and painful body sites associated with pain-related impact.Copyright © 2018 Database: EMBASE

90. Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study Author(s): Sort R.; Nielsen J.K.; Moller A.M.; Brorson S.; Gogenur I. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Peripheral nerve blocks (PNB) are increasingly used for anaesthesia and postoperative pain control in acute orthopaedic limb surgery but rebound pain upon cessation of PNBs may challenge the benefits on the pain profile. We aimed to explore the pain profile following acute ankle fracture surgery under PNB anaesthesia and investigate if rebound pain could pose a clinical problem. Methods: Exploratory, observational study of adults scheduled for acute primary internal fixation of an ankle fracture under ultrasound- guided popliteal sciatic and saphenous ropivacaine block anaesthesia. Postoperatively, patients regularly registered pain scores while receiving a fixed analgesics regimen and patient controlled morphine on-demand. We analysed morphine consumption and depicted the detailed pain profiles as graphs allowing for visual analysis of pain courses, including rebound pain. Secondly, we compared the area under the curve and peak pain between relevant age-subgroups. Results: We included 21 patients aged 20-83. Depicted pain profiles reveal that PNB supplied effective and long lasting postoperative pain control, but cessation of the PNB led to intense rises in pain scores with six out of nine 20-60-year-olds reaching severe pain levels. The rebound was less pronounced in patients >60 years old, but nearly all reached moderate pain levels. Morphine consumption rates were high during the rebound. Conclusions: This study thoroughly analyses the post-PNB pain profile and suggests rebound pain is a clinically relevant and problematic issue with the potential to outweigh the PNB benefits, especially for younger patients. The conclusions are tentative, and a randomised study is pending.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

91. The Relationship of Endocannabinoidome Lipid Mediators With Pain and Psychological Stress in Women With Fibromyalgia: A Case-Control Study Author(s): Stensson N.; Ghafouri N.; Gerdle B.; Ghafouri B.; Ernberg M.; Mannerkorpi K.; Kosek E. Source: Journal of Pain; Nov 2018; vol. 19 (no. 11); p. 1318-1328 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29885369 Abstract:Characterized by chronic widespread pain, generalized hyperalgesia, and psychological stress, fibromyalgia (FM) is difficult to diagnose and lacks effective treatments. Endocannabinoids-arachidonoylethanolamide (AEA), 2-arachidonoylglycerol (2-AG), and the related oleoylethanolamide (OEA), palmitoylethanolamide (PEA), and stearoylethanolamide (SEA)-are endogenous lipid mediators with analgesic and anti-inflammatory characteristics, in company with psychological modulating properties (eg, stress and anxiety), and are included in a new emerging "ome," the endocannabinoidome. This case-control study compared the concentration differences of AEA, OEA, PEA, SEA, and 2-AG in 104 women with FM and 116 healthy control subjects. All participants rated their pain, anxiety, depression, and current health status. The relationships between the lipid concentrations and the clinical assessments were investigated using powerful multivariate data analysis and traditional bivariate statistics. The concentrations of OEA, PEA, SEA, and 2-AG were significantly higher in women with FM than in healthy control subjects; significance remained for OEA and SEA after controlling for body mass index and age. 2-AG correlated positively with FM duration and body mass index, and to some extent negatively with pain, anxiety, depression, and health status. In FM, AEA correlated positively with depression ratings. The elevated circulating levels of endocannabinoidome lipids suggest that these lipids play a role in the complex pathophysiology of FM and might be signs of ongoing low- grade inflammation in FM. Although the investigated lipids are significantly altered in FM, their biological roles are uncertain with respect to the clinical manifestations of FM. Thus plasma lipids alone are not good biomarkers for FM. Perspective: This study reports about elevated plasma levels of endocannabinoidome lipid mediators in FM. The lipids' suitability to work as biomarkers for FM in the clinic were low; however, their altered levels indicate that a metabolic asymmetry is ongoing in FM, which could serve as a baseline during explorative FM pain management.Copyright © 2018 the American Pain Society Database: EMBASE

92. Spouse Criticism/Hostility Toward Partners With Chronic Pain: The Role of Spouse Attributions for Patient Control Over Pain Behaviors Author(s): Burns J.W.; Gerhart J.; Buvanendran A.; Post K.M.; Smith D.A.; Porter L.S.; Fras A.M.; Keefe F.J. Source: Journal of Pain; Nov 2018; vol. 19 (no. 11); p. 1308-1317 Publication Date: Nov 2018 Publication Type(s): Article PubMedID: 29864506 Abstract:Spouse attributions regarding displays of pain behaviors by their partners with chronic pain may account for subsequent increases in spouse critical/hostile responses toward their partners. People with chronic low back pain (n = 105) and their pain-free spouses (n = 105) completed electronic diary measures 5 times per day for 14 consecutive days. Key items assessed spouse observations of patient pain behavior, attributions regarding these behaviors, and spouse critical/hostile responses toward patients. Results were 1) spouse observations of patient pain behavior at time 1 predicted high levels of spouse critical/hostile responses toward the patient at time 2. 2) "Internal" attributions (eg, the patient was attempting to influence spouse's feelings) at time 1 predicted high levels of spouse critical/hostile responses toward the patient at time 2. 3) Internal attributions mediated links between spouse-observed pain behaviors at time 1 and levels of spouse critical/hostile responses at time 2. Spouse observations of patient pain behavior was also related to an "external" attribution (ie, patient pain behavior was due to pain condition), but this attribution was not a significant mediator. A vital factor linking spouse scrutiny to spouse critical/hostile responses may be the spouse's ascribed reasons for the patient's grimacing, bracing, complaining, and so forth. Perspective: Results indicate that spouse internal and negative attributions for pain behaviors of their partners with chronic pain may influence subsequent spouse critical/hostile reactions to them. Findings suggest that replacing spouse internal and negative attributions with external, compassionate, and accepting explanations may be useful therapeutic targets for couples coping with chronic pain.Copyright © 2018 the American Pain Society Database: EMBASE

93. Comparison of the effects of modified pectoral nerve block and erector spinae plane block on postoperative opioid consumption and pain scores of patients after radical mastectomy surgery: A prospective, randomized, controlled trial Author(s): Altiparmak B.; Turan M.; Gumus Demirbilek S.; Korkmaz Toker M.; Uysal A.I. Source: Journal of Clinical Anesthesia; May 2019; vol. 54 ; p. 61-65 Publication Date: May 2019 Publication Type(s): Article Abstract:Study objective: Breast cancer is the most common malignancy of women all over the world. In this study, we compared the effects of ultrasound-guided modified pectoral nerve (PECS) block and erector spinae plane (ESP) block on postoperative opioid consumption, pain scores, and intraoperative fentanyl need of patients undergoing unilateral modified radical mastectomy surgery. Design: Single-blinded, prospective, randomized, efficacy study. Setting: Tertiary university hospital, postoperative recovery room and surgical ward. Patients: Forty patients (ASA I-II) were allocated to two groups. After exclusion, 38 patients were included in the final analysis (18 patients in the PECS groups and 20 in the ESP group). Interventions: Modified pectoral nerve block was performed in the PECS group and erector spinae plane block was performed in the ESP group. Measurements: Postoperative tramadol consumption and pain scores were compared between the groups. Also, intraoperative fentanyl need was measured. Main results: Postoperative tramadol consumption was 132.78 +/- 22.44 mg in PECS group and 196 +/- 27.03 mg in ESP group (p = 0.001). NRS scores at the 15th and 30th min were similar between the groups. However, median NRS scores were significantly lower in PECS group at the postoperative 60th min, 120th min, 12th hour and 24th hour (p = 0.024, p = 0.018, p = 0.021 and p = 0.011 respectively). Intraoperative fentanyl need was 75 mg in PECS group and 87.5 mg in ESP group. The difference was not statistically significant (p = 0.263). Conclusion: Modified PECS block reduced postoperative tramadol consumption and pain scores more effectively than ESP block after radical mastectomy surgery.Copyright © 2018 Elsevier Inc. Database: EMBASE

94. Does Sensorimotor Incongruence Trigger Pain and Sensory Disturbances in People With Chronic Low Back Pain? A Randomized Cross-Over Experiment Author(s): Don S.; Venema M.; De Kooning M.; Nijs J.; Voogt L.; van Buchem B. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Chronic low back pain (CLBP) has major public health implications, and underlying mechanisms are still unclear. Sensorimotor incongruence (SMI)-an ongoing mismatch between top-down motor output and predicted sensory feedback-may play a role in the course of chronic nonspecific low back pain. The hypothesis of this study was that the induction of SMI causes sensory disturbances and/or pain in people with CLBP and healthy volunteers. A sample of 66 people (33 people with CLBP and 33 healthy volunteers) participated in a visual feedback experiment involving real-time images of their own lower backs-either during movement or in a static position-provided via a live video feed. Experimental SMI was induced via distorting visual feedback of the lower back during movement. There were no significant differences in sensory disturbances or pain intensity between experimental SMI and the other movement conditions in people with CLBP and healthy volunteers (P >.05). Static visual feedback had a significant effect on the intensity of sensory disturbances in people with CLBP (P =.038) and healthy volunteers (P <.001). In conclusion, experimental SMI did not affect sensory disturbances or pain in either group. Therefore, the research hypothesis was not supported. Perspective: The results of this study show that sensorimotor incongruence does not cause additional symptoms and pain in people with chronic low back pain. The conceptual premise that sensorimotor incongruence is an underlying contributor in the course of pain in this population is not supported.Copyright © 2018 Database: EMBASE

95. Exposure and cognitive-behavioural therapy for chronic back pain: An RCT on treatment processes Author(s): Schemer L.; Glombiewski J.A.; Schroeder A.; Ornbol E. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: To improve treatment outcomes, it is essential to understand the processes involved in therapeutic change. The aim of this study was to investigate the processes involved in treatment of individuals with chronic lower back pain (CLBP) and high fear-avoidance. Graded in vivo exposure (Exposure), a specific treatment, and cognitive- behavioural therapy (CBT), a general treatment, were compared. Methods: Our study used data from a three-arm randomized controlled trial. The sample comprised 61 CLBP patients (pain duration >3 months; sufficient level of fear-avoidance). Assessments of session-by- session processes were done weekly for a maximum 14 weeks. The primary outcome, functional disability, was assessed at pre-treatment, post-treatment and 6-months follow- up. First, two-level models were used to test for treatment-related similarities and differences in the changes in session-by-session measures (i.e., common and unique treatment processes respectively). Second, we analysed treatment processes as predictors of treatment outcome. Results: Contrary to our expectations, we found no evidence of unique treatment processes. Our results indicate that Exposure and CBT share some treatment processes. Specifically, patients reported a reduction in fear of movement and improvements in their ability to relax, to distract themselves, to manage their pain, to confront feared movements, to be active and to enjoy things despite their pain. Changes in fear of movement, relaxation, distraction, confrontation, activity and pain-related self- efficacy were also related to disability reduction. Conclusions: Despite conceptual differences, Exposure and CBT may share common treatment processes. Future research needs to address, however, whether these processes need to be targeted directly or can be supported indirectly. Significance: We identified several treatment processes (e.g., reduction of fear of movement, enhancement of self-efficacy), which were associated with disability reduction during the management of chronic pain and fear-avoidance. These processes appeared to be equally important for Exposure and CBT. Practitioners should optimize these processes to improve their patients' functioning.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

96. Comparison of cardiac output optimization with an automated closed-loop goal- directed fluid therapy versus non standardized manual fluid administration during elective abdominal surgery: first prospective randomized controlled trial Author(s): Lilot M.; Bellon A.; Bouvet L.; Vassal O.; Lehot J.-J.; Gueugnon M.; Laplace M.-C.; Baffeleuf B.; Hacquard P.; Barthomeuf F.; Parent C.; Tran T.; Soubirou J.-L.; Piriou V.; Robinson P. Source: Journal of Clinical Monitoring and Computing; Dec 2018; vol. 32 (no. 6); p. 993-1003 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 29380190 Abstract:An intraoperative automated closed-loop system for goal-directed fluid therapy has been successfully tested in silico, in vivo and in a clinical case-control matching. This trial compared intraoperative cardiac output (CO) in patients managed with this closed-loop system versus usual practice in an academic medical center. The closed-loop system was connected to a CO monitoring system and delivered automated colloid fluid boluses. Moderate to high-risk abdominal surgical patients were randomized either to the closed- loop or the manual group. Intraoperative final CO was the primary endpoint. Secondary endpoints were intraoperative overall mean cardiac index (CI), increase from initial to final CI, intraoperative fluid volume and postoperative outcomes. From January 2014 to November 2015, 46 patients were randomized. There was a lower initial CI (2.06 vs. 2.51 l min-1 m-2, p = 0.042) in the closed-loop compared to the control group. No difference in final CO and in overall mean intraoperative CI was observed between groups. A significant relative increase from initial to final CI values was observed in the closed-loop but not the control group (+ 28.6%, p = 0.006 vs. + 1.2%, p = 0.843). No difference was found for intraoperative fluid management and postoperative outcomes between groups. There was no significant impact on the primary study endpoint, but this was found in a context of unexpected lower initial CI in the closed-loop group. Trial registry number ID-RCB/EudraCT: 2013-A00770-45. ClinicalTrials.gov Identifier NCT01950845, date of registration: 17 September 2013.Copyright © 2018, Springer Science+Business Media B.V., part of Springer Nature. Database: EMBASE

97. Is a history of severe episodic low back pain an indicator of a discogenic etiology? Author(s): Levi D.; Carnahan D.; Horn S.; Levin J. Source: Pain Medicine (United States); 2018; vol. 19 (no. 7); p. 1334-1339 Publication Date: 2018 Publication Type(s): Article Abstract:Objective. To determine if a history of severe episodic low back pain (LBP) correlates with positive discography. Methods. A retrospective chart review identified patients undergoing discography from January 2012 through February 2016. The review determined if the patient's LBP began or continued with severe disabling episodes (lasting a minimum of two days). A gradual onset or initiating event with continuous symptoms was considered a nonepisodic history. Patients were excluded for unclear record, workers' compensation, litigation, prior lumbar surgery, radiologic instability, or indeterminate discography. Results. Seventy-eight patients underwent discography. Thirty-nine patients were included, 31 of which had positive discograms. Eight had negative discograms. Nineteen patients had a history of episodic LBP, and 20 had no history of episodic LBP. Of those 19 with a history of episodic LBP, 18 had positive discography and one had negative discography. Of those with no history of episodic LBP, 13 had positive discography and seven had negative discography. Using the historical finding of severe episodic LBP as a test for discogenic source of LBP, the sensitivity is 58% (95% confidence interval [CI] 5 41-75%) and the specificity is 88% (95% CI565-100%). The likelihood ratio is 4.7 (95% CI50.72-30). The positive predictive value (PPV) is 95% (95% CI572-100%). The PPV is based upon a prevalence of 79% (discogram positive) in our sample of patients considering fusion surgery. The diagnostic confidence odds are 18.2, with a diagnostic confidence of 95%. Conclusions. A positive history of severe episodic LBP may be a strong indicator for a discogenic etiology.Copyright © 2017 American Academy of Pain Medicine. Database: EMBASE

98. Prospective validation of a new airway management algorithm and predictive features of intubation difficulty Author(s): Cook F.; Lobo D.; Martin M.; Imbert N.; Grati H.; Daami N.; Cherait C.; Saidi N.-E.; Abbay K.; Jaubert J.; Younsi K.; Bensaid S.; Ait-Mamar B.; Slavov V.; Mounier R.; Bloc S.; Catineau J.; Goater P.; Abdelhafidh K.; Haouache H.; Dhonneur G. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Some patients have features that indicate possible difficulty with direct laryngoscopy for tracheal intubation. Prediction of the likely outcome and selection of patients for an enhanced management algorithm would reduce the possible harm from failed intubation attempts. Methods: Adult elective patients were assessed for seven features associated with difficult direct laryngoscopy, ranked in difficulty from 0 to 3. For a patient with at least one Class 3 feature, or two or more features that were classed 1 or more, the enhanced management used a channelled video laryngoscope AirtraqTM instead of a Macintosh laryngoscope. A long flexible angulated stylet and a flexible fibrescope would be used as the second and third steps. For patients with lesser difficulty scores, a Macintosh laryngoscope was used. Outcomes of enhanced management were analysed. Logistic regression and Random Forest algorithm, using the ranks of the predictive features, were used to predict difficulty during enhanced management. Results: We prospectively studied 16 695 patients. We selected 1501 (9%) for enhanced management, and tracheal intubation was successful in all of them. Of these, 73% were intubated in less than 30 s, and only 4.5% required more than 4 min for intubation. Progression to the second and third steps of enhanced management was predicted by restriction of mouth opening and reduced cervical spine mobility. Conclusions: An enhanced management algorithm allowed successful tracheal intubation of all patients with anticipated difficult laryngoscopy. The need to combine the use of a stylet and a fibrescope with the AirtraqTM could be predicted with a high degree of certainty.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

99. Effects of thoracic epidural analgesia on exercise-induced myocardial ischaemia in refractory angina pectoris Author(s): Gonon A.; Janerot-Sjoberg B.; Novak J.; Richter A.; Cederholm I.; Khan J.; Milovanovic M. Source: Acta Anaesthesiologica Scandinavica; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Acta Anaesthesiologica Scandinavica - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Thoracic epidural analgesia (TEDA) was offered to patients with refractory angina pectoris. Our primary objectives were to evaluate TEDAs' influence on quality of life (QoL, base for power analysis), and hypothesising that TEDA with bupivacaine during 1 month counteracts exercise-induced myocardial hypoperfusion and increase physical performance. Methods: Patients with refractory angina and exercise inducible hypoperfusion, as demonstrated by myocardial perfusion imaging (MPI), were randomised to 1-month treatment with TEDA with bupivacaine (B-group, n = 9) or saline (P-group, n = 10) in a double-blind fashion. MPI and bicycle ergometry were performed before TEDA and after 1 month while subjective QoL on a visual analogue scale (VAS) reported by the patients was checked weekly. Results: During this month VAS (mean [95%CI]) increased similarly in both groups (B-group from 33 [18-50] to 54 [30-78] P < 0.05; P-group from 40 [19-61] to 48 [25-70] P < 0.05). The B-group reduced their exertional-induced myocardial hypoperfusion (from 32% [12-52] to 21% [3-39]; n = 9; P < 0.05), while the P-group showed no significant change (before 21% [6-35]; at 1 month 23% [6-40]; n = 10). MPI at rest did not change and no improvement in physical performance was detected in neither of the groups. Conclusions: In refractory angina, TEDA with bupivacaine inhibits myocardial ischaemia in contrast to TEDA with saline. Regardless of whether bupivacaine or saline is applied intermittently every day, TEDA during 1 month improves the quality of life and reduces angina, even when physical performance remains low. A significant placebo effect has to be considered.Copyright © 2018 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd Database: EMBASE

100. The Impact of Chronic Discogenic Low Back Pain: Costs and Patients' Burden Author(s): Geurts J.W.; Van Kleef M.; Kallewaard J.-W.; Willems P.C.; Dirksen C. Source: Pain Research and Management; 2018; vol. 2018 Publication Date: 2018 Publication Type(s): Article PubMedID: 30364097 Available at Pain research & management - from Europe PubMed Central - Open Access Available at Pain research & management - from Hindawi Open Access Journals Available at Pain research & management - from Pubmed Central - Open Access Abstract:Introduction. Chronic discogenic low back pain (CDP) is frequently diagnosed in patients referred to specialized pain clinics for their back pain. The aim of this study is to assess the impact of CDP both on the individual patient and on society. Materials and Methods. Using the baseline records of 80 patients in a randomized trial assessing the effectiveness of a new intervention for CDP, healthcare and societal costs related to back pain are calculated. Furthermore, the impact of the condition on perceived pain, disability, health-related quality of life, Quality of life Adjusted Life Years (QALY), and QALY loss is assessed. Results. Using the friction costs approach, we found that the annual costs for society are 7,911.95 per CDP patient, 51%healthcare and 49%societal costs. When using the human capital approach, total costs were 18,940.58, 22%healthcare and 78%societal costs. Healthcare costs were mainly related to pain treatment. Mean pain severity was 6.5 (0-10), and 46%suffered from severe pain (>=7/10). Mean physical limitations rate was 43.7; 13.5%of the patients were very limited to disabled. QALY loss compared to a healthy population was 64%. Discussion. This study shows that in patients with CDP referred to a pain clinic, costs for society are high and the most used healthcare resources are pain therapies. Patients suffer severe pain, are physically limited, and experience a serious loss in quality of life.Copyright © 2018 Jose W. Geurts et al. Database: EMBASE

101. A prospective, randomized, comparison study on effect of perioperative use of chloride liberal intravenous fluids versus chloride restricted intravenous fluids on postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass grafting surgeries Author(s): Bhaskaran K.; Arumugam G.; Vinay Kumar P.V. Source: Annals of Cardiac Anaesthesia; 2018; vol. 21 (no. 4); p. 413-418 Publication Date: 2018 Publication Type(s): Article PubMedID: 30333337 Available at Annals of cardiac anaesthesia - from ProQuest (Hospital Premium Collection) - NHS Version Available at Annals of cardiac anaesthesia - from Europe PubMed Central - Open Access Available at Annals of cardiac anaesthesia - from Pubmed Central - Open Access Abstract:Context and Aims: Off-pump coronary artery bypass graft (OPCABG) is a form of CABG surgery. It is performed without the use of cardiopulmonary bypass machine as a surgical treatment for coronary heart disease. Acute kidney injury (AKI) is one of the common postoperative complications of OPCABG. Previous studies suggest important differences related to intravenous fluid (IVF) chloride content and renal function. We hypothesize that perioperative use of chloride restricted IVFs may decrease incidence and severity of postoperative AKI in patients undergoing OPCABG. Methods: Six hundred patients were randomly divided into two groups of 300 each. In Group A (n = 300), chloride liberal IVFs, namely, hydroxyethyl starch (130/0.4) in 0.9% normal saline (Voluven), 0.9% normal saline, and Ringer's lactate were used for perioperative fluid management. In Group B (n = 300), chloride-restricted IVFs, namely, hydroxyethyl starch (130/0.4) in balanced colloid solution (Volulyte) and balanced salt crystalloid solution (PlasmaLyte A), were used for perioperative fluid management. Serum creatinine values were taken preoperatively, postoperatively at 24 h and at 48 h. Postoperative AKI was determined by AKI network (AKIN) criteria. Results: In Group A, 9.2% patients and in Group B 4.6% patients developed Stage-I AKI determined by AKIN criteria which was statistically significant (P < 0.05). Conclusion: Perioperative use of chloride restricted IVF was found to decrease incidence of postoperative AKI. The use of chloride liberal IVF was associated with hyperchloremic metabolic acidosis.Copyright © 2018 Annals of Cardiac Anaesthesia Published by Wolters Kluwer-Medknow. Database: EMBASE

102. Predictors and outcome of early extubation in infants postcardiac surgery: A single- center observational study Author(s): Alam S.; Mazahir R.; Shalini A.; Hegde R.G.; Jain A. Source: Annals of Cardiac Anaesthesia; 2018; vol. 21 (no. 4); p. 402-406 Publication Date: 2018 Publication Type(s): Article PubMedID: 30333334 Available at Annals of cardiac anaesthesia - from ProQuest (Hospital Premium Collection) - NHS Version Available at Annals of cardiac anaesthesia - from Europe PubMed Central - Open Access Available at Annals of cardiac anaesthesia - from Pubmed Central - Open Access Abstract:Objective: The objective of the current study was to evaluate the timing of first extubation and compare the outcome of patient extubated early with others; we also evaluated the predictors of early extubation in our cohort. Materials and Methods: This prospective cohort study included children <1 year of age undergoing surgery for congenital heart disease. Timing of first extubation was noted, and patients were dichotomized in the group taking 6 h after completion of surgery as cutoff for early extubation. The outcome of the patients extubated early was compared with those who required prolonged ventilation. Variables were compared between the groups, and predictors of early extubation were evaluated using multivariate logistic regression analysis. Results: One hundred and ninety- four (33.8%) patients were extubated early including 2 extubation in operating room and 406 (70.7%) were extubated within 24 h. Four (0.7%) patients died without extubation. No significant difference in mortality and reintubation was observed between groups. Patient extubated early had a significant lower incidence of sepsis (P = 0.003) and duration of Intensive Care Unit (ICU) stay (P = 0.000). Age <6 months, risk adjustment for congenital heart surgery category >=3, cardiopulmonary bypass time >=80 min, aortic cross-clamp time >= 60 min, and vasoactive-inotropic score >10 were independently associated with prolonged ventilation. Conclusion: Early extubation in infants postcardiac surgery lowers pediatric ICU stay and sepsis without increasing the risk of mortality or reintubation. Age more than 6 months, less complex of procedure, shorter surgery time, and lower inotropic requirement are independent predictors of early extubation.Copyright © 2018 Annals of Cardiac Anaesthesia Published by Wolters Kluwer-Medknow. Database: EMBASE

103. A prospective randomized trial of prognostic genicular nerve blocks to determine the predictive value for the outcome of cooled radiofrequency ablation for chronic knee pain due to osteoarthritis Author(s): Reddy R.; Korn M.; McCarthy R.J.; Khan D.; Nagpal G.; Walega D.R.; Dayanim D.; Bouffard K.; Syed R.H.; Bhave M.; Zhukalin M.; Choxi S.; Ebrahimi A.; Kendall M.C.; McCormick Z.L. Source: Pain Medicine (United States); 2018; vol. 19 (no. 8); p. 1628-1638 Publication Date: 2018 Publication Type(s): Article Abstract:Background and Objectives. Genicular nerve radiofrequency ablation is an effective treatment for patients with chronic pain due to knee osteoarthritis; however, little is known about factors that predict procedure success. The current study evaluated the utility of genicular nerve blocks to predict the outcome of genicular nerve cooled radiofrequency ablation (cRFA) in patients with osteoarthritis. Methods. This randomized comparative trial included patients with chronic knee pain due to osteoarthritis. Participants were randomized to receive a genicular nerve block or no block prior to cRFA. Patients receiving a prognostic block that demonstrated 50% pain relief for six hours received cRFA. The primary outcome was the proportion of participants with 50% reduction in knee pain at six months. Results. Twenty-nine participants (36 knees) had cRFA following a prognostic block, and 25 patients (35 knees) had cRFA without a block. Seventeen participants (58.6%) in the prognostic block group and 16 (64.0%) in the no block group had 50% pain relief at six months (P 5 0.34). A 15-point decrease in the Western Ontario and McMaster Universities Osteoarthritis Index at six months was present in 17 of 29 (55.2%) in the prognostic block group and 15 of 25 (60%) in the no block group (P 5 0.36). Conclusions. This study demonstrated clinically meaningful improvements in pain and physical function up to six months following cRFA. A prognostic genicular nerve block using a local anesthetic volume of 1 mL at each injection site and a threshold of 50% pain relief for subsequent cRFA eligibility did not improve the rate of treatment success.Copyright © 2017 American Academy of Pain Medicine. All rights reserved. Database: EMBASE

104. Screening for adult ADHD in patients with fibromyalgia syndrome Author(s): Van Rensburg R.; Meyer H.P.; Hitchcock S.A.; Schuler C.E. Source: Pain Medicine (United States); 2018; vol. 19 (no. 9); p. 1825-1831 Publication Date: 2018 Publication Type(s): Article Abstract:Objective. Fibromyalgia syndrome (FMS) is a common chronic pain disorder associated with altered activity of neurotransmitters involved in pain sensitivity such as dopamine, serotonin, and noradrenaline. FMS may significantly impact an individual's functioning due to the presence of chronic pain, fatigue, and cognitive impairment. Dyscognition may be more disabling than the chronic pain but is mostly under-recognized. This study aimed to assess the potential co-occurrence of FMS and adult attention deficit hyperactivity disorder (ADHD), a chronic neurodevelopmental disorder also associated with impaired cognition and dopaminergic function. Methods. In a cross-sectional observational study, 123 previously confirmed FMS patients were screened for adult ADHD using the World Health Organization Adult ADHD Self Report scale v1.1. The Revised Fibromyalgia Impact Questionnaire (FIQ-R) was used to assess the impact of FMS. Cognitive assessment was based on self-report in accordance with the 2011 modified American College of Rheumatology criteria and the FIQ-R, respectively. Results. Of the 123 participants, 44.72% (N 5 55) screened positive for adult ADHD. Participants with both FMS and a positive adult ADHD screening test scored higher on the FIQ-R score (64.74, SD 5 17.66, vs 54.10, SD 5 17.10). Self-reported cognitive impairment was rated higher in the combined group (odds ratio 5 10.61, 95% confidence interval; 3.77-29.86, P < 0.01). Conclusions. These results indicate that the co-occurrence of adult ADHD in FMS may be highly prevalent and may also significantly impact the morbidity of FMS. Patients with FMS should be assessed for the presence of adult ADHD.Copyright © 2017 American Academy of Pain Medicine. All rights reserved. Database: EMBASE

105. Management Strategies for Severe and Refractory Acute Respiratory Distress Syndrome: Where Do We Stand in 2018? Author(s): Nasim R.; Sukhal S.; Ramakrishna H. Source: Journal of Cardiothoracic and Vascular Anesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Database: EMBASE

106. Ultrasound guided repositioning of a new suture-method catheter for adductor canal block - A randomized pilot study in healthy volunteers Author(s): Jordahn Z.M.; Lyngeraa T.S.; Rothe C.; Lundstrom L.H.; Lange K.H.W.; Grevstad U. Source: BMC Anesthesiology; Oct 2018; vol. 18 (no. 1) Publication Date: Oct 2018 Publication Type(s): Article PubMedID: 30355334 Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Abstract:Background: We performed a randomized, blinded pilot study in 12 volunteers to assess the feasibility to reposition an intentionally displaced suture-method catheter for two different insertion techniques for adductor canal block. Methods: Each volunteer had an ultrasound-guided suture-method catheter placed in the adductor canal (AC) in both legs. The catheters were placed using a perpendicular technique in one leg and a parallel technique in the other leg, according to randomization. 15 mL lidocaine 1% (LA) was injected in each catheter. Successful primary placement was defined as combined LA spread within the AC and loss of cold sensation 15 min after injection. All catheters were intentionally displaced, and subsequently repositioned using ultrasound. Another dose of lidocaine (15 mL 1%) was injected through the catheters and assessed for successful repositioning. Results: Successful primary placement was achieved in 83% (95% CI 55-95%) of catheters placed perpendicular to the AC, and in 75% (95% CI 47-91%) of catheters placed parallel to the AC. Of those with successful primary placement, 100% (95% CI 72-100%) of catheters placed perpendicular to the AC, and 67% (95% CI 35-88%)) placed parallel to the AC could be repositioned. Conclusions: Placement and secondary repositioning after displacement of a suture-method catheter within the adductor canal is achievable. A perpendicular technique seems more reliable. Trial registration: NCT03315481 clinicaltrials.gov. The study was submitted on March 1, 2017. Due to clerical error, the study was posted on October 20, 2017.Copyright © 2018 The Author(s). Database: EMBASE

107. Best perioperative practice in management of ambulatory patients with obstructive sleep apnea Author(s): Nagappa M.; Subramani Y.; Chung F. Source: Current opinion in anaesthesiology; Dec 2018; vol. 31 (no. 6); p. 700-706 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 30199402 Abstract:RECENT FINDINGS: A recent meta-analysis found that STOP-Bang might be used as a perioperative risk stratification tool. Patients with high-risk OSA (STOP-Bang >=3) were found to be associated with an increased risk of postoperative complications and prolonged length of hospital stay compared with low-risk OSA (STOP-Bang 0-2) patients undergoing noncardiac surgical procedures. A bidirectional relationship exists between OSA and difficult airway. Both suspected or diagnosed OSA may be associated with either difficult intubation or difficult mask ventilation or both. A recent meta-analysis identified OSA as an important risk factor for opioid-induced respiratory depression. A dose-response relationship was shown between the morphine equivalent daily dose and death or near-death events in OSA patients undergoing surgery. Postoperative continuous monitoring is recommended for high-risk OSA patients receiving opioids. Minimising the dose of muscle relaxant, neuromuscular monitoring and ensuring complete reversal of neuromuscular blockade before extubation is essential in OSA patients to avoid postoperative complications. Whenever feasible, regional anesthesia with multimodal analgesia may be considered as a better alternative to general anesthesia in OSA patients.SUMMARY: Patients with OSA and associated comorbidities present a challenge to anesthesiologists as they are at a high risk of perioperative complications. It is important to identify patients with OSA, with the goal to raise awareness among providers, mitigate risk and improve outcomes.PURPOSE OF REVIEW: The perioperative outcome in obstructive sleep apnea (OSA) patients undergoing ambulatory surgery can be potentially impacted by the type of anesthetic technique, fluid management and choice of anesthetic agents. This review highlights the best perioperative practices in the management of OSA patients undergoing ambulatory surgical procedures. Database: EMBASE

108. Rebound pain after regional anesthesia in the ambulatory patient Author(s): Lavand'homme P. Source: Current opinion in anaesthesiology; Dec 2018; vol. 31 (no. 6); p. 679-684 Publication Date: Dec 2018 Publication Type(s): Article PubMedID: 30124544 Abstract:PURPOSE OF REVIEW: Regional anesthesia is popular in ambulatory setting allowing safe and fast recovery. The problem of 'rebound pain', that is very severe pain when peripheral nerve block (PNB) wears off represents a clinically relevant problem and a cause of increased healthcare resource utilization. This review tries to make the point on a not so rare, unwanted and often neglected side effect of PNB.RECENT FINDINGS: The major finding is the lack of large prospective studies. Incidence of rebound pain is unknown but could reach 40% of patients at PNB resolution. To date, pathophysiological mechanisms remain debated: mechanical and chemical (proinflammatory effect of local anesthetics) nerve insult caused by PNB in predisposed patients (with severe preoperative pain, younger patients). Effective preventive strategies also are missing (e.g. role of analgesic adjuvants in PNB). Long-term consequences in term of functional recovery and persistent pain have not been demonstrated. Interview of patients has underlined the need of information and education about PNB and postoperative analgesia.SUMMARY: Patients' report of excruciating pain and major distress when PNB wears off questions the quality of current anesthesia practice in ambulatory setting. Rebound pain unanswered questions are challenging in the area of perioperative medicine. Database: EMBASE

109. Family Caregivers' Subjective Caregiving Burden, Quality of Life, and Depressive Symptoms Are Associated With Terminally Ill Cancer Patients' Distinct Patterns of Conjoint Symptom Distress and Functional Impairment in Their Last Six Months of Life Author(s): Wen F.-H.; Chen J.-S.; Chou W.-C.; Chang W.-C.; Shen W.C.; Hsieh C.-H.; Tang S.T. Source: Journal of Pain and Symptom Management; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Context: Family caregivers constitute a critical component of the end-of-life care system with considerable cost to themselves. However, the joint association of terminally ill cancer patients' symptom distress and functional impairment with caregivers' subjective caregiving burden, quality of life (QOL), and depressive symptoms remains unknown. Objectives/Methods: We used multivariate hierarchical linear modeling to simultaneously evaluate associations between five distinct patterns of conjoint symptom distress and functional impairment (symptom-functional states) and subjective caregiving burden, QOL, and depressive symptoms in a convenience sample of 215 family caregiver-patient dyads. Data were collected every 2 to 4 weeks over patients' last 6 months. Results: Caregivers of patients in the worst symptom-functional states (States 3-5) reported worse subjective caregiving burden and depressive symptoms than those in the best two states, but the three outcomes did not differ between caregivers of patients in State 3 and States 4-5. Caregivers of patients in State 5 endured worse subjective caregiving burden and QOL than those in State 4. Caregivers of patients in State 4 suffered worse subjective caregiving burden and depressive symptoms but comparable QOL to those in State 2. Conclusion: Patients' five distinct, conjoint symptom-functional states were significantly and differentially associated with their caregivers' worse subjective caregiving burden, QOL, and depressive symptoms while caring for patients over their last 6 months.Copyright © 2018 American Academy of Hospice and Palliative Medicine Database: EMBASE

110. Alterations in Temporal Summation of Pain and Conditioned Pain Modulation Across an Episode of Experimental Exercise-Induced Low Back Pain Author(s): McPhee M.; Graven-Nielsen T. Source: Journal of Pain; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Persistent pain conditions, including low back pain (LBP), are often accompanied by alterations in pronociceptive and antinociceptive mechanisms, as quantified by temporal summation of pain (TSP) and conditioned pain modulation (CPM). It remains unclear whether altered pain sensitivity, CPM, and/or TSP are a consequence of pain presence or determine the degree of pain development. Pressure pain sensitivity, TSP, and CPM were assessed across an episode of exercise-induced LBP maintained for several days. Thirty healthy individuals participated in 3 experimental sessions: before (day 0), 2 days after fatiguing back muscle exercise with exercise-induced LBP present (day 2), and after pain resolution (day 7). Both handheld and cuff pressure-pain thresholds, along with TSP (10-cuff pain stimuli at.5 Hz) and CPM (cuff pain detection threshold prior versus during painful pressure conditioning) were assessed, alongside questionnaires pertaining to pain, disability, mood, sleep, menstruation, physical activity, and catastrophizing. The exercise- induced LBP model produced mild pain and disability, and reductions in pressure pain thresholds over both the lumbar and distant testing sites (p <.007). No pain-related changes were observed for TSP (p >.44) or CPM (p >.17). The baseline TSP was associated with the peak pain intensity of the exercise-induced LBP (p <.003). Perspective: Pressure-pain sensitivity was impacted by the presence of exercise-induced LBP, whereas TSP seemed to be more stable and was instead associated with the intensity of pain developed. No significant pain-related changes or associations were observed for CPM, suggesting this measure may have less usefulness in mild musculoskeletal pain conditions.Copyright © 2018 Database: EMBASE

111. Laryngeal mask airway UniqueTM position in paediatric patients undergoing magnetic resonance imaging (MRI): Prospective observational study Author(s): Klucka J.; Stoudek R.; Toukalkova M.; Krikava I.; Stourac P.; Senkyrik J.; Skotakova J.; Marecek L.; Pavlik T.; Stouracova A. Source: BMC Anesthesiology; Oct 2018; vol. 18 (no. 1) Publication Date: Oct 2018 Publication Type(s): Article PubMedID: 30355285 Available at BMC anesthesiology - from BioMed Central Available at BMC anesthesiology - from Europe PubMed Central - Open Access Available at BMC anesthesiology - from Pubmed Central - Open Access Abstract:Background: Laryngeal mask UNIQUE (LMAU) is supraglottic airway device with good clinical performance and low failure rate. Little is known about the ideal position of the LMAU on the magnetic resonance imaging (MRI) and whether radiological malposition can be associated with clinical performance (audible leak) in children. The primary aim of the study was to evaluate incidence of the radiologic malposition of the LMAU according to size. The secondary outcome was the clinical performance and associated complications (1st attempt success rate, audible leak) in LMAUs in correct position vs. radiologically misplaced LMAUs. Methods: In prospective observational study, all paediatric patients undergoing MRI of the brain under general anaesthesia with the LMAU were included (1.9.2016-16.5.2017). The radiologically correct position: LMAU in hypopharynx, proximal cuff opposite to the C1 or C2 and distance A (proximal cuff end and aditus laryngis) <= distance B (distal cuff end and aditus laryngis). Malposition A: LMAU outside the hypopharynx. Malposition B: proximal cuff outside C1-C2. Malposition C: distance A >= distance B. We measured distances on the MRI image. Malposition incidence between LMAU sizes and first attempt success rate in trainees and consultant groups was compared using Fisher exact test, difference in incidence of malpositions using McNemar test and difference in leakage according to radiological position using two-sample binomial test. Results: Overall 202 paediatric patients were included. The incidence of radiologically defined malposition was 26.2% (n = 53). Laryngeal mask was successfully inserted on the 1st attempt in 91.1% (n = 184) cases. Audible leak was detected in 3.5% (n = 7) patients. The radiologically defined malposition was present in 42.9% (n = 3) cases with audible leak. The rate of associated complications was 1.5% (n = 3): laryngospasm, desaturation, cough. In 4.0% (n = 8) the LMAU was soiled from blood. Higher incidence of radiological malposition was in LMAU 1.0, 1.5 and LMAU 3, 4 compared to LMAU 2 or LMAU 2.5 (p < 0.001). Conclusion: Malposition was not associated with impaired clinical performance (audible leak, complications) of the LMAU or the need for alternative airway management. Trial registration: Clinicaltrials.gov (NCT02940652) Registered 18 October 18 2016.Copyright © 2018 The Author(s). Database: EMBASE

112. Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty Author(s): Cozowicz C.; Liu J.; Weinstein S.M.; Pichler L.; Memtsoudis S.G.; Poeran J.; Zubizarreta N.; Mazumdar M. Source: British Journal of Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Abstract:Background: Studies on the effectiveness of multimodal analgesia, particularly in patients at higher perioperative risk from obstructive sleep apnoea (OSA), are lacking. We aimed to assess the impact of multimodal analgesia on opioid use and complications in this high-risk cohort. Methods: We conducted a population-based retrospective cohort study of OSA patients undergoing elective lower extremity joint arthroplasty (2006-16, Premier Healthcare database). Multimodal analgesia was defined as opioid use with the addition of one, two, or more non-opioid analgesic modes including, nonsteroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, peripheral nerve blocks, steroids, gabapentin/pregabalin, or ketamine. Multilevel multivariable regression models measured associations between multimodal analgesia and opioid prescription (primary outcome; oral morphine equivalents). Secondary outcomes included opioid- and OSA-related complications, and resource utilisation. Odds ratios (OR) or % change and 95% confidence intervals (CI) are reported. Results: Among 181 182 OSA patients included, 88.5% (n = 160 299) received multimodal analgesia with increasing utilisation trends. Multivariable models showed stepwise beneficial postoperative outcome effects with increasing additional analgesic modes compared with opioid-only analgesia. In patients who received more than two additional analgesia modes (n = 64 174), opioid dose prescription decreased by 14.9% (CI -17.0%; -12.7%), while odds were significantly decreased for gastrointestinal complications (OR 0.65, CI 0.53; 0.78), mechanical ventilation (OR 0.23, CI 0.16; 0.32), and critical care admission (OR 0.60, CI 0.48; 0.75), all P<0.0001. Conclusions: In a population at high risk for perioperative complications from OSA, multimodal analgesia was associated with a stepwise reduction in opioid use and complications, including critical respiratory failure.Copyright © 2018 British Journal of Anaesthesia Database: EMBASE

113. A retrospective comparison of propofol to dexmedetomidine for pediatric magnetic resonance imaging sedation in patients with mucopolysaccharidosis type II Author(s): Kang R.; Shin Y.H.; Gil N.-S.; Oh Y.N.; Hahm T.S.; Jeong J. Source: Paediatric Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pediatric Anesthesia - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Mucopolysaccharidosis type II patients are reported to have an elevated incidence of difficult airway. Propofol is a commonly used sedative for magnetic resonance imaging in pediatric patients, but patients who receive it may exhibit dose- dependent upper airway obstruction and respiratory depression. Dexmedetomidine also provides adequate procedural sedation with a relatively low risk of airway obstruction. Accordingly, we introduced the use of dexmedetomidine in our practice to reduce the risk of airway obstruction during magnetic resonance imaging procedures. Aims: The aim of this study was to evaluate the incidence of artificial airway interventions in patients sedated with propofol and compare it to that in patients sedated with dexmedetomidine in patients with mucopolysaccharidosis type II during magnetic resonance imaging procedures. Methods: All mucopolysaccharidosis type II patients undergoing magnetic resonance imaging at our institution between April 2014 and February 2018 were included in this study. The patients were divided into two groups according to whether they were managed before and after the introduction of dexmedetomidine: those who were sedated with propofol (group P) and those who were sedated with dexmedetomidine (group D). Results: Forty-six sedations were performed in 27 patients. Artificial airway interventions were significantly more frequent during propofol-based than dexmedetomidine-based sedation: 14 of 32 (43.8%) in group P and 1 of 14 (7.1%) in group D (odds ratio, 10.11; 95% confidence interval, 1.18-86.85; P = 0.018). Time to awake and time to discharge were similar between groups. Changes in hemodynamic variables also did not significantly differ between groups. Conclusion: Dexmedetomidine provides an adequate level of sedation and is associated with lower rates of artificial airway interventions compared to propofol. Therefore, dexmedetomidine may offer advantages for preserving the native airway compared to propofol when administered during magnetic resonance imaging scans in patients with mucopolysaccharidosis type II.Copyright © 2018 John Wiley & Sons Ltd Database: EMBASE

114. Opioid Induced Hyperalgesia with Intrathecal Infusion of High-Dose Fentanyl Author(s): Kalaydjian A.; Farah F.; Cheng Y.; Gerges F.J.; Acquadro M.A. Source: Pain Practice; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Pain Practice - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Introduction: Despite being reported since 1943 as well as being the subject of a large body of literature since that time, no consensus has been reached regarding the etiology of opioid induced hyperalgesia (OIH). It is often described as a paradoxical increased pain response to noxious stimuli due to increased sensitization or an acute tolerance to opioids. Case: We report the case of a 60 year old patient on chronic Intrathecal combined fentanyl and Bupivacaine who had worsening pain with increasing doses and improved after weaning off intrathecal opioids. Conclusion: OIH has been described in various settings including patients on methadone maintenance therapy, perioperative opioid administration, cancer patients on opioids, and healthy volunteers who are acutely exposed to opioids, including high dose intrathecal opioids such as Morphine and Sufentanil. To our knowledge, no cases of opioid induced hyperalgesia was previously reported in the case of intrathecal Fentanyl.Copyright © 2018 World Institute of Pain Database: EMBASE

115. Sensory disturbances induced by sensorimotor conflicts are higher in complex regional pain syndrome and fibromyalgia compared to arthritis and healthy people, and positively relate to pain intensity Author(s): Brun C.; Mercier C.; Grieve S.; McCabe C.S.; Palmer S.; Bailey J. Source: European Journal of Pain (United Kingdom); 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at European Journal of Pain - from Wiley Online Library Medicine and Nursing Collection 2018 - NHS Abstract:Background: Sensorimotor conflicts are well known to induce sensory disturbances. However, explanations as to why patients with chronic pain are more sensitive to sensorimotor conflicts remain elusive. The main objectives of this study were (a) to assess and compare the sensory disturbances induced by sensorimotor conflict in complex regional pain syndrome (n = 38), fibromyalgia (n = 36), arthritis (n = 34) as well as in healthy volunteers (HV) (n = 32); (b) to assess whether these disturbances were related to the intensity and duration of pain, or to other clinical variables assessed using questionnaires (abnormalities in sensory perception, depression and anxiety); and (c) to categorize different subgroups of conflict-induced sensory disturbances. Methods: One hundred and forty participants performed in phase or anti-phase movements with their arms while viewing a reflection of one arm in a mirror (and the other arm obscured). They were asked to report changes in sensory disturbances using a questionnaire. Results: First, results showed that patients with complex regional pain syndrome and fibromyalgia were more prone to report sensory disturbances than arthritis patients and HV in response to conflicts (small effect size). Second, conflict-induced sensory disturbances were correlated with pain intensity (large effect size) and abnormalities in sensory perception (only in the CRPS group) but were not related to the duration of the disease or psychological factors. Finally, we identified two distinct subgroups of conflict-induced sensory disturbances. Conclusions: Our results suggest that pain lowers the threshold for the detection of sensorimotor conflicts, a phenomenon that could contribute to the maintenance of pain in clinical populations. Significance: Individuals with complex regional pain syndrome and fibromyalgia were more sensitive to sensorimotor conflicts than arthritis patients and controls. Moreover, conflict- induced sensory disturbances were specific to higher pain intensity and higher sensory abnormalities in all groups, suggesting that pain lowers the threshold for the detection of sensorimotor conflicts.Copyright © 2018 European Pain Federation - EFIC Database: EMBASE

116. The effect of dexmedetomidine on delirium and agitation in patients in intensive care: systematic review and meta-analysis with trial sequential analysis Author(s): Ng K.T.; Shubash C.J.; Chong J.S. Source: Anaesthesia; 2018 Publication Date: 2018 Publication Type(s): Article In Press Available at Anaesthesia - from Wiley Abstract:Delirium is common in intensive care patients. Dexmedetomidine is increasingly used for sedation in this setting, but its effect on delirium remains unclear. The primary aim of this review was to examine whether dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients. We sought randomised clinical trials in MEDLINE, EMBASE, PubMed and CENTRAL from their inception until June 2018. Observational studies, case reports, case series and non-systematic reviews were excluded. Twenty-five trials including 3240 patients were eligible for inclusion in the data synthesis. In the patients who received dexmedetomidine (eight trials, 1425 patients), delirium was reduced, odds ratio (95%CI) 0.36 (0.26-0.51), p < 0.001 and high quality of evidence. The use of dexmedetomidine was associated with a reduced incidence of agitation, OR (95%CI) 0.34 (0.20-0.59), p < 0.001, moderate quality of evidence. Patients who were randomly assigned to dexmedetomidine had a significantly higher incidence of bradycardia, OR (95%CI) 2.18 (1.46-3.24), p < 0.001, moderate quality of evidence; and hypotension, OR (95%CI) 1.89 (1.48-2.41), p < 0.001, high quality of evidence. We found no evidence of an effect on mortality, OR (95%CI) 0.86 (0.66-1.10), p = 0.23, moderate quality of evidence. The trial sequential analyses for the incidence of delirium, bradycardia and hypotension was conclusive but not for the incidence of agitation and mortality. In summary, this meta- analysis suggests that dexmedetomidine reduces the incidence of delirium and agitation in intensive care patients. The general quality of evidence ranged from moderate to high.Copyright © 2018 Association of Anaesthetists Database: EMBASE