Background Managing COVID-19-positive patients requiring surgery is complex due to perceived heightened perioperative risks. However, Canadian data in this context remains scarce. To address this gap, we conducted a multicenter cohort study in the province of Québec, the Canadian province most affected during the initial waves of the pandemic, to comprehensively assess the impact of COVID-19 symptoms, and recovery time, on postoperative outcomes in surgical patients. Methods We included adult surgical patients with either active COVID-19 at time of surgery or those who had recovered from the disease, from March 13, 2020, to April 30, 2021. We evaluated the association between symptoms or recovery time and postoperative pulmonary complications and hospital mortality using multivariable logistic regression and Cox models. Results We included 105 patients with an active infection (47 were symptomatic and 58 were asymptomatic) and 206 who had healed from COVID-19 in seven hospitals. Among patients with an active infection, those who were symptomatic had a higher risk of pulmonary complications (odds ratio = 3.19; 95% CI, from 1.12 to 9.68; p = 0.03) and hospital mortality (hazard ratio = 3.67; 95% CI, from 1.19 to 11.32; p = 0.02). We did not observe any significant effect of the duration of recovery prior to surgery on patients who had healed from their infection. Their postoperative outcomes were also similar to those observed in asymptomatic patients. Interpretation Symptomatic status should be considered in the decision to proceed with surgery in COVID-19-positive patients. Our results may help optimize surgical care in this patient population. Trial registration: ClinicalTrials.gov Identifier: NCT04458337, Registration Date: July 7, 2020.

ObjectivesOur primary objective was to assess the association between symptoms at the time of surgery and postoperative pulmonary complications and mortality in patients with COVID-19. Our secondary objective was to compare postoperative outcomes between patients who had recovered from COVID-19 and asymptomatic patients and explore the effect of the time elapsed between infection and surgery in the former. Our hypotheses were that symptomatic patients had a higher risk of pulmonary complications, whereas patients who had recovered from the infection would exhibit outcomes similar to those of asymptomatic patients.BackgroundManaging COVID-19-positive patients requiring surgery is complex due to perceived heightened perioperative risks. However, Canadian data in this context remains scarce.DesignTo address this gap, we conducted a multicentre observational cohort study.SettingAcross seven hospitals in the province of Québec, the Canadian province was most affected during the initial waves of the pandemic.ParticipantsWe included adult surgical patients with either active COVID-19 at the time of surgery or those who had recovered from the disease, from March 22, 2020 to April 30, 2021.OutcomesWe evaluated the association between symptoms or recovery time and postoperative pulmonary complications and hospital mortality using multivariable logistic regression and Cox models. The primary outcome was a composite of any postoperative pulmonary complication (atelectasis, pneumonia, acute respiratory distress syndrome and pneumothorax). Our secondary outcome was hospital mortality, assessed from the date of surgery up to hospital discharge.ResultsWe included 105 patients with an active infection (47 were symptomatic and 58 were asymptomatic) at the time of surgery and 206 who had recovered from COVID-19 prior to surgery in seven hospitals. Among patients with an active infection, those who were symptomatic had a higher risk of pulmonary complications (OR 3.19, 95% CI 1.12 to 9.68, p=0.03) and hospital mortality (HR 3.67, 95% CI 1.19 to 11.32, p=0.02). We did not observe any significant effect of the duration of recovery prior to surgery on patients who had recovered from their infection. Their postoperative outcomes were also similar to those observed in asymptomatic patients.InterpretationSymptomatic status should be considered in the decision to proceed with surgery in COVID-19-positive patients. Our results may help optimise surgical care in this patient population.Study registrationClinicalTrials.gov Identifier:NCT04458337registration date: 7 July 2020.

Introduction Published data on the safety of natural medical cannabis (MC) when used in the real-world clinical practice setting are lacking. This study aimed to describe adverse events (AEs) reported across three years following MC initiation. Methods The Quebec Cannabis Registry (QCR) was a prospective registry of adults enrolled through participating physicians when they initiated MC between May 2015 and October 2018. Follow-up ended at MC discontinuation, loss to follow-up, three years, or end of data collection (May 2019). Data were collected at baseline and at follow-up visits every three months for the first two years, then once in the third year. Physicians filled adverse event (AE) reports, which were coded using MedDRA ® preferred terms (PTs), and descriptive analyses were conducted. Results A total of 2991 patients were enrolled (mean age 50.9 years, 50.2% females). During follow-up, 108 patients (3.6%) experienced moderate or severe AEs, yielding 111 AE reports (three patients had two reports) and 214 AEs (average 1.9 AEs per report). Mild AEs were recorded as a reason for MC discontinuation for nine patients, but no AE reports were available. The most common PTs for ingested MC (62 reports) were dizziness (12.9%), nausea (11.3%), somnolence (9.7%), and vomiting (8.1%), and for inhaled MC (23 reports), headache (13.0%) was the most common. The most frequent PTs associated with tetrahydrocannabinol (THC)-dominant MC (25 reports) were dizziness and somnolence (12.0% each); for cannabidiol (CBD)-dominant MC (20 reports), vomiting (20.0%) was most common; and dizziness (17.2%), nausea (13.8%), somnolence (10.3%), and headache (8.6%) were the most frequent for balanced MC (58 reports). Conclusion No new safety concerns were identified relative to the published literature, although notable differences in AE profile between modes of administration and cannabinoid content ratios should be considered by health professionals. Further work identifying and managing risk factors for AEs is warranted to maintain a favorable benefit-risk balance for MC.

Objective: To investigate the safety and effectiveness of medical cannabis (MC) in the real-world clinical practice setting. Design: A 4-year prospective noncomparative registry of adult patients who initiated MC for a variety of indications. This paper reports on patients followed for up to 12 months, with interim visits at 3, 6, and 9 months after enrollment. Setting: Public or private outpatient clinics certified to authorize MC in the province of Quebec, Canada. Participants: Overall, 2991 adult (age ≥18 years) patients (mean age 51 years; 50.2% women) were enrolled between May 2015 and October 2018, with the last follow-up ending in May 2019. Interventions/Exposures: Cannabis products (dried, oil, or other) purchased from a Canadian licensed cannabis producer as authorized by physicians. Main Outcome Measures: The primary outcomes were self-reported pain severity, interference and relief (Brief Pain Inventory [BPI]), symptoms using the Revised Edmonton Symptom Assessment System (ESAS-r) and health-related quality of life dimensions (EQ-5D-5L) at baseline and each follow-up visit. The secondary outcomes were self-reported adverse events (AEs) and characteristics of cannabis treatment. Results: All patient-reported outcomes (BPI, ESAS-r, and EQ-5D-5L) showed a statistically significant improvement at 3 months (all p<0.01), which was maintained or further improved (for pain interference, tiredness, and well-being) over the remainder of the 12-month follow-up. Results also revealed clinically significant improvements in pain interference and tiredness, anxiety, and well-being from baseline. There were 79 AE reports (77 patients), 16 met the regulatory definition of seriousness, in which only 8 AEs were certainly or probably related to MC. Conclusions: MC directed by physicians appears to be safe and effective within 3 months of initiation for a variety of medical indications.

OBJECTIVE:Many patients with fibromyalgia (FM) report using cannabis as a strategy to improve pain. Given that pain often co-occurs with symptoms of anxiety and depression (i.e., negative affect) and sleep problems among patients with FM, improvements in these symptoms might indirectly contribute to reductions in pain intensity following cannabis use. The main objective of the study was to examine whether changes in pain intensity following initiation of medical cannabis among patients with FM could be attributed to concurrent changes (i.e., reductions) in negative affect and sleep problems. METHODS:This was a 12-month prospective cohort study among patients with FM (n = 323) initiating medical cannabis under the care of physicians. Patients were assessed at baseline, and follow-up assessment visits occurred every 3 months after initiation of medical cannabis. Patients' levels of pain intensity, negative affect, and sleep problems were assessed across all visits. RESULTS:Multilevel mediation analyses indicated that reductions in patients' levels of pain intensity were partly explained by concurrent reductions in sleep problems and negative affect (both P < 0.001). This remained significant even when accounting for patients' baseline characteristics or changes in medical cannabis directives over time (all P > 0.05). CONCLUSION:Our findings provide preliminary insight into the potential mechanisms of action underlying pain reductions among patients with FM who are using medical cannabis. Given the high attrition rate (i.e., 75%) observed in the present study at 12 months, our findings cannot be generalized to all patients with FM who are using medical cannabis.

Emergence from anesthesia is a critical period and cough can result in adverse effects. Propofol inhibits airway reflexes and when infused it reduces cough more than inhalation anesthesia does. We evaluated the effect of a propofol bolus given at emergence on the incidence of coughing following a desflurane-based anesthesia. One hundred and fifty-four patients scheduled for elective surgery were prospectively randomized to propofol (0.5 mg·kg−1) or normal saline (NS) administered at the end of the surgery at 1 minimum alveolar concentration (MAC) of desflurane. A “no touch” emergence technique was used until extubation. The primary outcome was the incidence of cough at the discontinuation of desflurane (T0) and reaching a MAC adjusted for age (MACage) of 0.15. Secondary outcomes included incidence and severity of cough until five minutes postextubation (T0–T5), time to extubation, nausea and vomiting, sedation, hemodynamic variations, postoperative hypoventilation, hypoxemia, and sore throat. We could not draw inferences on the incidence of cough between T0 and MACage of 0.15 because only 27/68 (40

Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada E-mail address: [email protected] (P. Beaulieu) Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

O bloqueio PECS I foi descrito pela primeira vez para cirurgia envolvendo os músculos peitorais. Nenhum estudo clínico randomizado foi realizado em procedimentos envolvendo diretamente os músculos peitorais, como a mamoplastia de aumento submuscular. Nossa hipótese foi de que o bloqueio PECS I diminuiria a dor pós‐operatória nessa população. Realizamos estudo randomizado, duplo‐cego, controlado por placebo em mulheres submetidas à mamoplastia de aumento submuscular. Realizamos o bloqueio PECS I com 0,4 mL.kg‐1 de solução salina a 0,9% de um lado e bupivacaína (0,25%) do outro lado, sendo cada paciente seu próprio controle. Os escores da Escala de Avaliação Numérica (EAN) de dor (0 − 10) foram obtidos em repouso e durante movimento. O desfecho primário foi o escore de dor em repouso 30 minutos após a chegada à SRPA. Para detectar uma diferença clinicamente significante de 50% na redução da dor, 14 voluntárias foram incluídas (poder de 90% e alfa < 0,05). Na SRPA, três pacientes não apresentaram diferença na dor entre os lados, cinco relataram menos dor no lado do placebo e seis, menos dor no lado da bupivacaína. No grupo bupivacaína, os escores de dor em repouso aos 5, 30 e 60 minutos e 24 horas foram 4,89 (4,23 − 5,56; IC médio 95%), 3,75 (3,13 − 4,37), 3,79 (2,93 − 4,64) e 2,29 (1,56 − 3,01), respectivamente, enquanto no grupo placebo foram 4,96 (4,32 − 5,60), 4,00 (3,50 − 4,49), 3,93 (3,12 − 4,73) e 2,29 (1,56 − 3,01), respectivamente. O bloqueio PECS I em pacientes submetidas a mamoplastia de aumento não oferece melhor alívio da dor do que o placebo. Portanto, as indicações para bloqueio de PECS I na cirurgia de aumento de mama devem ser reconsideradas. PECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population. This was a randomized, double‐blind, placebo‐controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg‐1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0 − 10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha < 0.05). In the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23 − 5.56; mean 95% CI), 3.75 (3.13 − 4.37), 3.79 (2.93 − 4.64), and 2.29 (1.56 − 3.01), respectively, whereas in the placebo group, they were 4.96 (4.32 − 5.60), 4.00 (3.50 − 4.49), 3.93 (3.12 − 4.73), and 2.29 (1.56 − 3.01), respectively. PECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.

12109 Background: The Quebec Cannabis Registry (QCR) was launched in 2015 to allow physicians to prescribe medical cannabis (MC) in the province of Quebec, Canada. This study aimed to investigate the safety and effectiveness of MC in cancer patients using pharmacovigilance data prospectively collected for up to 24 months. Methods: Patients were enrolled in the QCR between May 2015 and October 2018 and followed every 3 months. Study outcomes included adverse events (AE), pain severity and interference (Brief-Pain Inventory), wellbeing (Revised-Edmonton Symptom Assessment Scale) and overall health scale (EQ5D5L) at baseline and at each follow-up (F-UP). Significance of changes over time were assessed using repeated-measures ANOVA. Results: Out of the 2991 patients enrolled in the QCR, 358 (12.8%) were cancer patients (mean age 57.7 (± 14.6); 171 (47.8%) males). The main cancer types were breast (16.2%), lung (11.7%), leukemia (11.5%) and colorectal (11.2%). MC was prescribed primarily for pain (72.1%), anxiety (4.7%), nausea (4.5%), anorexia (3.9%), and insomnia (3.1%). A total of 13 patients (3.6%) reported AE with only three being serious (one unrelated to MC: stroke; and two possibly related: diarrhea, from CBD oil overdose and pneumonia from smoking MC). Mean scores significantly (p < 0.05) improved between baseline and 3 months F-UP for pain severity (4.8 ± 1.5 vs 4.1 ± 1.8), pain interference (4.6 ± 1.8 vs 3.8 ± 1.7), and the overall health scale (60 ± 21 vs 71 ± 18). Well-being scores also significantly improved between baseline and 6 months F-UP (4.4 ± 2.1 vs 3.5 ± 2.8). Conclusions: Population-based data shows that cancer patients can benefit safely and effectively from MC as a complementary treatment, when prescribed and monitored under medical-nursing supervision.

M. Gabrielle Pagé, PhD, yY Irina Kudrina, MD, CM,z Hervé Tchala Vignon Zomahoun, PhD,§ Jordie Croteau, MSc, Daniela Ziegler, MSi,jj Patrice Ngangue, PhD, Elisabeth Martin, MSc, Maude Fortier, BSc, Esthelle Ewusi Boisvert, BA, Pierre Beaulieu, MD, PhD,yy Céline Charbonneau,zz Jennifer Cogan, MD, MSc,y§§ Raoul Daoust, MD, MSc, Marc O. Martel, PhD,jjjj Andrée Néron, BPharm, FOPQ, Philippe Richebé, MD, PhD,yyy and Hance Clarke, MD, PhDzzz§§§

BACKGROUND AND OBJECTIVES:PECS I block was first described for surgery involving the pectoralis muscles. No randomized clinical trial has been conducted on surgeries that directly involve these muscles, such as subpectoral breast augmentation. We hypothesized that PECS I block would decrease pain in the postoperative period in this population. METHODS:This was a randomized, double-blind, placebo-controlled trial in women undergoing subpectoral breast augmentation surgery. PECS I block was performed using 0.4 mL.kg-1 of 0.9% saline on one side and bupivacaine (0.25%) on the other side, each patient being her own control. Numeric Rating Scale (NRS) pain scores (0-10) were measured at rest and during movement. The primary outcome was pain score at rest 30 minutes after arrival in the PACU. To detect a clinically significant difference of 50% in pain reduction, 14 volunteers were enrolled (power of 90% and alpha<0.05). RESULTS:In the PACU, three patients had no difference in pain between sides, five had reduced pain on the placebo side, and six had reduced pain on the bupivacaine side. In the bupivacaine group, pain scores at rest at 5, 30 and 60 minutes and 24 hours were 4.89 (4.23-5.56; mean 95% CI), 3.75 (3.13-4.37), 3.79 (2.93-4.64), and 2.29 (1.56-3.01), respectively, whereas in the placebo group, they were 4.96 (4.32-5.60), 4.00 (3.50-4.49), 3.93 (3.12-4.73), and 2.29 (1.56-3.01), respectively. CONCLUSIONS:PECS I block in patients undergoing breast augmentation surgery does not provide better pain relief than placebo. Therefore, the indications for PECS I block in breast augmentation surgery should be reconsidered.

Introduction/Aim: The objectives of this systematic review and meta-analysis were to examine the relative frequency and risk factors (patient, surgical, medical, clinical) for prolonged opioid therapy among surgical and trauma patients. Methods: Studies published in English and French between 1998 and April 2018 examining risk factors for prolonged (3–6 months) or chronic (>6 months) opioid use after surgery/trauma were included. Literature search: seven databases were queried, empirical studies were identified via direct and back citation search, grey literature was also included. A minimum of two independent reviewers assessed studies for inclusion, extracted data and assessed studies quality. Results: Thirty-five out of 10,003 screened articles were included. The median relative frequency of prolonged (50.9%) and chronic (58.5%) opioid therapy among pre-event patients already on opioid therapy was much higher compared to pre-event opioid naïve patients (4.1% and 2.6%, respectively). Tobacco use, depressive disorder and antidepressants use were significant risk factors for prolonged and/or chronic opioid therapy among pre-event opioid naïve patients. Tobacco use, depressive disorder and history of migraines were risk factors for prolonged opioid therapy among pre-event opioid-treated patients. Discussion/Conclusions: Prevention initiatives to reduce the risk of prolonged opioid therapy after surgery or trauma should target specific health behaviors and psychiatric disorders; these interventions should be tailored based on patients’ pre-event opioid status.

Nous rapportons le cas d’un homme de 63 ans qui a présenté brutalement en peropératoire une obstruction totale iatrogène de la sonde d’intubation endotrachéale par un corps étranger avec pour résultat une ventilation impossible. L’évolution fut favorable après reintubation du patient. La cause de l’incident fut détectée à posteriori. Un examen minutieux a mis en évidence une occlusion complète de la lumière de la sonde d’intubation endotrachéale par un pansement plastique transparent type Opsite®.We report the case of a 63-year-old man with sudden mechanical ventilation failure due to acute iatrogenic complete obstruction of the endotracheal tube by a foreign body. The thorough examination of the endotracheal tube shows an obstruction by a plastic transparent dressing.

Introduction: During general anesthesia, emergence is a critical period 1 where cough can result in adverse effects. 2,3 Given that propofol inhibits airway reflexes 4 , and that total intravenous anesthesia reduces cough when compared to inhalation anesthesia 5,6 , we hypothesized that giving a propofol bolus at emergence of a desflurane-based general anesthesia would decrease coughing incidence and severity.Methods: Following local Ethics Board approval,154 ASA I-III patients between 18 to 80 years of age that were scheduled for an elective surgery consented to be randomized to either the propofol or the control group.The patients underwent standardized general anesthesia, during which opioids were allowed except for a given period before the surgery ended -10 minutes for remifentanil, and 20 minutes for fentanyl and sufentanil.Either a propofol bolus (0.5 mg/kg) or normal saline (0.05 ml/kg) bolus was administered at the end of the surgery at 1 MAC.Then, desflurane was discontinued and fresh oxygen flow was increased to 10 L/min.A standardized "no touch" emergence technique was used.A blinded assessor noted the incidence and severity of cough during emergence of anesthesia on a 4 points scale, up until 5 min post-extubation.Time to extubation, postoperative nausea and vomiting, and respiratory complications were also recorded.These recovery profiles and hemodynamic parameters were compared between the groups.Based on a 30% local incidence of emergence cough, a sample size of 70 patients per group was necessary to detect a clinically significant 50% reduction in cough incidence (power 80%; alpha 5%).Statistical analyses were performed using a contingency table and a chi-square test for independence on categorical data and a Student's t-test for continuous variables.Results: There were no significant differences in the coughing incidence between the propofol and control groups (95.9% vs. 83.8%, p = 0.064).The cough intensity was also unaffected, see Table 1.Coughing occurred at an average of 0.12 MAC of desflurane in each group.Time to extubation was prolonged by 3 min 26 s for the propofol group (10 min 41 s vs. 7 min 14 s, p < 0,01).This group also needed more vasopressors at emergence (n = 8 vs. n = 1, p = 0.035).There was a statistically significant, although not clinically relevant, higher sore throat score in the propofol group (VAS 1.7 vs.

The pectoral nerves (PECS) I block, first described in 2011 for surgery involving the pectoralis muscle, has principally been used for breast cancer surgery. No formal evaluation of its differential motor- and sensory-blocking abilities has been reported. We hypothesize that the PECS I block will produce a motor block of the pectoralis muscles with diminished upper limb adduction strength as measured with a handheld dynamometer.

OBJECTIVE The aim of this study was to examine the relative frequency of and risk factors for prolonged opioid prescription (Rx_3-6: ≥1 opioid prescription of any length between 3 and 6 months postevent) and long-term opioid prescription (Rx_>6: ≥1 opioid prescription of any length >6 months postevent) after surgery/trauma. SUMMARY BACKGROUND DATA Eighty percent of patients undergoing surgery are prescribed opioids; for many this initial time-limited therapy continues for months after surgery. METHODS Included studies were published between January 1998 and April 2018, examined opioid use ≥3 months after surgery/trauma requiring hospitalization, and considered pre-event opioid prescription status. Empirical studies were identified via a systematic literature search. Two independent reviewers assessed studies for inclusion and conducted data extraction and quality appraisal. RESULTS Thirty-five of the 10,003 screened articles were included; most were retrospective studies of medicoadministrative databases; all studies were observational. The median relative frequency of Rx_3-6 and Rx_>6 was 4.1% and 2.6%, respectively, among patients with no/short-term opioid prescription pre-event and 50.9% and 58.5%, respectively, among patients with prolonged opioid prescription pre-event. Income levels, tobacco dependence, use of antidepressants, and pre-event opioid prescriptions are associated with increased risk of Rx_3-6/Rx_>6. The use of benzodiazepines (current use) or muscle relaxants and the presence of alcohol/drug dependence were found to be potential risk factors for Rx_3-6/Rx_>6 among patients with no/short-term opioid prescription pre-event. CONCLUSIONS Identified risk factors for Rx_3-6/Rx_>6 were predominantly psychosocial factors. This points to the importance of assessing mental and social health before surgery and acutely during hospitalization to ensure safe and optimal recovery.This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0.