A multi-institutional, propensity-score-matched comparison of post-operative outcomes between general anesthesia and monitored anesthesia care with intravenous sedation in umbilical hernia repair

Effectiveness and Safety of Intravenous Sedation with Propofol in Non-Operating Room Anesthesia (NORA) for Dental Treatment in Uncooperative Paediatric Patients

Background: Uncooperative children require sedative approach for dental treatment. The aim was to assess the effectiveness of Propofol in “Non-Operating Room Anesthesia” (NORA) for paediatric dental treatment; intraoperative side effects; postoperative side effects; post-discharge effects. Methods: a prospective study, involving 109 uncooperative children undergoing sedation in NORA using Propofol for dental treatment, was performed. Working sessions, success/failure, intraoperative and postoperative side effects, number of treatment; type of procedure were assessed. Parents completed a post-discharge questionnaire on: pain; crying; fever; vomiting; headache; drowsiness; excitability; irritability; ability to eat; drugs and medical care needing. Results: Success: 96.7%. Intraoperative side effects: 33.3%. Postoperative side effects: 6.4%. Statistically significant association between: intraoperative side effects and age (p = 0.001), health status (p = 0.0007), weight (p = 0.038), respectively; intraoperative side effects and number/ type of dental treatment (p = 0.0055) and scaling (p = 0.0001), respectively. For post-discharge questionnaires, statistically significant association between: age and crying (p = 0.0001) and headache (p = 0.002), respectively; health status and crying (p = 0.015) and drugs needing (p = 0.04), respectively; weight and crying (p = 0.0004); extraction and pain (p = 0.0001) and crying (p= 0.0073), respectively; scaling and crying (p = 0.04), excitability and irritability (p = 0.03), respectively. Conclusion: Propofol in NORA was effective with minimal side effects.

Repair of a medium-sized ventral hernia with the UltraPro Hernia System

Mesh repairs are widely accepted as a suitable option for ventral hernia repair. Among the various devices and surgical approaches used for ventral hernia repair, the UltraPro Hernia System (UHS) is considered an effective method of open repair for patients with medium ventral hernia defects between 3 and 5 cm in diameter. However, few clinical studies on this system have been reported. We describe a simple and safe UHS mesh technique for open ventral hernia repair, which was performed successfully under local anesthesia in 23 patients with medium ventral hernia defects. Minor postoperative complications included seroma (n = 3) and a superficial infection (n = 1). There was no incidence of recurrence in 12 months of follow-up. Our results show that the UHS is simple and easily reproducible for medium ventral hernia defects between 3 and 5 cm in diameter.

Outcomes after endoscopic retrograde cholangiopancreatography with general anaesthesia versus sedation

BACKGROUND

We tested the primary hypothesis that use of general anaesthesia vs sedation increases vulnerability to adverse discharge (in-hospital mortality or new discharge to a nursing facility) after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

In this retrospective cohort study, adult patients undergoing ERCP with general anaesthesia or sedation at a tertiary care hospital were included. We calculated adjusted absolute risk differences between patients receiving general anaesthesia vs sedation using provider preference-based instrumental variable analysis. We also used mediation analysis to determine whether intraoperative hypotension during general anaesthesia mediated its effect on adverse discharge.

RESULTS

Among 17 538 patients undergoing ERCP from 2007 through 2018, 16 238 received sedation and 1300 received GA. Rates of adverse discharge were 5.8% (n=938) after sedation and 16.2% (n=210) after general anaesthesia. Providers' adjusted mean predicted probabilities of using general anaesthesia for ERCP ranged from 0.2% to 63.2% of individual caseloads. Utilising provider-related variability in the use of general anaesthesia for instrumental variable analysis resulted in an 8.6% risk increase (95% confidence interval, 4.5-12.6%; P<0.001) in adverse discharge among patients receiving general anaesthesia vs sedation. Intraoperative hypotensive events occurred more often during general anaesthesia and mediated 23.8% (95% confidence interval, 3.9-43.7%: P=0.019) of the primary association.

CONCLUSIONS

These results suggest that use of sedation during ERCP facilitates reduced adverse discharge for patients for whom general anaesthesia is not clearly indicated. Intraoperative hypotension during general anaesthesia for ERCP partly mediates the increased vulnerability to adverse discharge.

Pain control for interstitial cystitis/bladder pain syndrome patients undergoing pelvic reconstructive surgery

Introduction:

Scant research exists on pain control for interstitial cystitis patients undergoing pelvic reconstructive surgery. Our aim was to compare the perioperative courses in patients with and without interstitial cystitis undergoing pelvic reconstructive surgery performed using primarily monitored anesthesia care with local anesthesia.

Methods:

A retrospective chart review of surgical cases performed at a single site from November 2015 to July 2018 was performed. Joint non-gynecologic cases were excluded. Data including demographics, intraoperative variables, medication requirements, and postoperative courses were abstracted. Chi-square, independent t, and Mann–Whitney U tests were used to compare interstitial cystitis with non-interstitial cystitis patients.

Results:

In total, 65 separate cases met inclusion criteria and were analyzed, with 57 individual subjects. Out of the 65 cases, 33 cases were performed on interstitial cystitis patients. Only 2 of the 33 interstitial cystitis patient cases required general anesthesia. Interstitial cystitis patients did not require higher concentrations of 1% lidocaine with epinephrine (average of 3.8 mg/kg) compared to patients without (2.8 mg/kg). There was no difference between groups in perioperative complications, length of recovery, or postoperative narcotic consumption.

Conclusion:

Perioperative outcomes and pain control do not differ in those with and without interstitial cystitis undergoing pelvic reconstructive surgery. Prolapse surgery can be safely performed on a patient population with a high proportion of chronic pelvic pain using monitored anesthesia care with local anesthesia, without increased morbidity or difficultly with perioperative pain control.

Safety of Deep Sedation in Patients Undergoing Full-Thickness Skin Graft Harvesting and Skin Graft Reconstruction for Limb Salvage An Outcome Analysis

BACKGROUND:

Studies on obtaining donor skin graft using intravenous sedation for patients undergoing major foot surgeries in the same operating room visit have not previously been reported. The objective of this retrospective study is to demonstrate that intravenous sedation in this setting is both adequate and safe in patients undergoing skin graft reconstruction of the lower extremities in which donor skin graft is harvested from the same patient in one operating room visit.

METHODS:

Medical records of 79 patients who underwent skin graft reconstruction of the lower extremities by one surgeon at the Yale New Haven Health System between November 1, 2008, and July 31, 2014, were reviewed. The patients' demographic characteristics, American Society of Anesthesiologists class, comorbid conditions, intraoperative analgesic administration, estimated blood loss, total operating room time, total postanesthesia care unit time, and postoperative complications within the first 72 hours were reviewed.

RESULTS:

This study found minimal blood loss and no postoperative complications, defined as any pulmonary or cardiac events, bleeding, admission to the intensive care unit, or requirement for invasive monitoring, in patients who underwent major foot surgery in conjunction with full-thickness skin graft.

CONCLUSIONS:

We propose that given the short duration and peripheral nature of the procedures, patients can safely undergo skin graft donor harvesting and skin graft reconstruction procedures with intravenous sedation regardless of American Society of Anesthesiologists class in one operating room visit.

Superion Interspinous Spacer Treatment of Moderate Spinal Stenosis: 4-Year Results

OBJECTIVE

To determine 4-year clinical outcomes in patients with moderate lumbar spinal stenosis treated with minimally invasive stand-alone interspinous process decompression using the Superion device.

METHODS

The 4-year Superion data were extracted from a randomized, controlled Food and Drug Administration investigational device exemption trial. Patients with intermittent neurogenic claudication relieved with back flexion who failed at least 6 months of nonsurgical management were enrolled. Outcomes included Zurich Claudication Questionnaire (ZCQ) symptom severity (ss), physical function (pf) and patient satisfaction (ps) subdomains, leg and back pain visual analog scale (VAS), and Oswestry Disability Index (ODI). At 4-year follow-up, 89 of the 122 patients (73%) provided complete clinical outcome evaluations.

RESULTS

At 4 years after index procedure, 75 of 89 patients with Superion (84.3%) demonstrated clinical success on at least 2 of 3 ZCQ domains. Individual component responder rates were 83% (74/89), 79% (70/89), and 87% (77/89) for ZCQss, ZCQpf, and ZCQps; 78% (67/86) and 66% (57/86) for leg and back pain VAS; and 62% (55/89) for ODI. Patients with Superion also demonstrated percentage improvements over baseline of 41%, 40%, 73%, 69%, and 61% for ZCQss, ZCQpf, leg pain VAS, back pain VAS, and ODI. Within-group effect sizes all were classified as very large (>1.0): 1.49, 1.65, 1.42, 1.12, and 1.46 for ZCQss, ZCQpf, leg pain VAS, back pain VAS, and ODI.

CONCLUSIONS

Minimally invasive implantation of the Superion device provides long-term, durable relief of symptoms of intermittent neurogenic claudication for patients with moderate lumbar spinal stenosis.