British journal of anaesthesia
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Randomized Controlled Trial Multicenter Study Comparative Study
Comparison of continuous with single-injection regional analgesia on patient experience after ambulatory orthopaedic surgery: A randomised multicentre trial.
The optimal approach to improving patient experience and analgesia after ambulatory orthopaedic surgery remains unclear. ⋯ NCT02720965.
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Randomized Controlled Trial
Dexamethasone and clinically significant postoperative nausea and vomiting: a prespecified substudy of the randomised perioperative administration of dexamethasone and infection (PADDI) trial.
Clinically significant postoperative nausea and vomiting (PONV) is a patient-reported outcome which reflects patient experience. Although dexamethasone prevents PONV, it is unknown what impact it has on this experience. ⋯ ACTRN12614001226695.
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Modified-release opioid tablets were introduced into surgical practice in the belief that they provided superior pain relief and reduced nursing workload, and they rapidly became embedded into many perioperative pathways. Although national and international guidelines for the management of postoperative pain now advise against the use of modified-release opioids, they continue to be prescribed in many centres. ⋯ Their slow onset and offset make rapid and safe titration of these opioids impossible, including down-titration as the patient recovers; pain relief may be less effective; they have been associated with an increased incidence of opioid-related adverse drug events, increased length of hospital stay, and higher readmission rates; and they lead to higher rates of opioid-induced ventilatory impairment and persistent postoperative opioid use. Evidence indicates that modified-release opioids should not be used routinely in the postoperative period.
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Editorial Comment Multicenter Study
Translating evidence into practice: still a way to go.
Chiu and colleagues report a retrospective analysis describing the 5-yr trend in both intraoperative fluid and vasopressor administration in 32 250 patients undergoing elective abdominal surgery within the Multicenter Perioperative Outcomes Group (MPOG) database from 2015 to 2019, and exploring the association between these two factors and acute kidney injury. Modelling predicted the lowest risk for acute kidney injury when the administered crystalloid volume was 15-20 ml kg-1 h-1, and an 80% increase in risk for acute kidney injury as intraoperative vasopressor use increased from 0 to 0.04 μg kg-1 min-1 of norepinephrine equivalents. Although these results are consistent with those of a large, randomised trial (REstrictive Versus LIbEral Fluid Therapy in Major Abdominal Surgery [RELIEF]) published in 2018, the mean intraoperative volume of crystalloid administered in the current study declined monotonically through every year included, from 6.4 ml kg-1 h-1 in 2015 to 5.5 ml kg-1 h-1 in 2019. These new findings support the broad generalisability of the RELIEF trial; highlight the complexity of the relationship between intravenous crystalloid volume infused, arterial pressure, and acute kidney injury; and demonstrate the ongoing challenge of translating high-quality evidence into clinical practice.