Factors Determining the Choice of Spinal Versus General Anesthesia in Patients Undergoing Ambulatory Surgery: Results of a Multicenter Observational Study

Utility of spinal anesthesia in plastic surgery and other surgical subspecialties: A literature review

INTRODUCTION

Spinal anesthesia (SA) is commonly used within the specialties of orthopedic surgery, obstetrics and gynecology, spine surgery, and general surgery, and offers several benefits over general anesthesia (GA). However, SA is used much less frequently in plastic surgery. This review analyzed currently existing data on SA use across various surgical specialties and compared the benefits and complications of SA to those of GA, to assess its utility and potential for more widespread use in plastic surgery.

METHODS

A comprehensive literature review was conducted using the PubMed and Cochrane Library databases to evaluate the utility of SA in plastic surgery. Indications, contraindications, and data on the use of SA across various surgical specialties were reviewed. Benefits, complications, and cost-effectiveness were also assessed. Finally, the utility of SA in plastic surgery was evaluated based on the available literature.

RESULTS

SA has been shown to yield several benefits and fewer risks than GA, including a higher possibility of early discharge, decreased costs, better pain and postoperative nausea and vomiting control, and decreased risk of deep venous thrombosis and pulmonary embolism.

CONCLUSION

Although commonly used for procedures across various surgical specialties such as obstetrics and gynecology, urology, and orthopedic surgery, SA is less frequently used within plastic surgery. Plastic surgery procedures that would benefit from the use of SA include those below the umbilicus such as liposuction, lower extremity procedures, and perineal procedures, and owing to its benefits, we recommend that SA be used more often within plastic surgery under appropriate clinical circumstances.

Is a Failed Spinal Attempt Associated with a Worse Clinical Course Following Primary Total Hip and Knee Arthroplasty?

INTRODUCTION

Spinal anesthesia (SA) is the preferred anesthesia modality for total joint arthroplasty (TJA). However, studies establishing SA as preferential may be subject to selection bias given that general anesthesia (GA) is often selectively utilized on more difficult, higher-risk operations. The optimal comparison group, therefore, is the patient converted to GA due to a failed attempt at SA. The purpose of this study was to determine risk factors and outcomes following failed SA with conversion to GA during primary total hip (THA) or knee arthroplasty (TKA).

METHODS

A consecutive cohort of 4,483 patients who underwent primary TJA at our institution was identified (2,004 THA and 2,479 TKA). Of these patients, 3,307 underwent GA (73.8%), 1,056 underwent SA (23.3%), and 130 patients failed SA with conversion to GA (2.90%). Primary outcomes included rescue analgesia requirement in the post-anesthesia care unit (PACU), time to ambulation, pain scores in the PACU, estimated blood loss (EBL), and 90-day complications.

RESULTS

Risk factors for SA failure included older age and a higher comorbidity burden. Failure of SA was associated with increased EBL, rescue intravenous (IV) opioid use, and time to ambulation when compared to the successful SA group in both THA and TKA patients (P < 0.001). The anesthesia modality was not associated with significant differences in PACU pain scores. The 90-day complication rate was similar between the failed SA and GA groups. There was a higher incidence of post-operative pain prompting unplanned visits and thromboembolism when comparing failed SA to successful SA in both THA and TKA patients (P < 0.05).

CONCLUSION

In our series, patients who had failed SA demonstrated inferior outcomes to patients receiving successful SA and similar outcomes to patients receiving GA who did not have an SA attempt. This emphasizes the importance of success in the initial attempt at SA for optimizing outcomes following TJA.

Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence

Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.

Increased Duration of Total Hip and Total Knee Arthroplasty Surgery Increases the Risk of Post-Operative Urinary Retention: A Retrospective Cohort Study

Background: Post-operative urinary retention (POUR) is a common complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Spinal anaesthetic has been associated with an increased risk of POUR, whilst other risk factors remain unclear. This study aims to identify modifiable and non-modifiable risk factors of POUR for THA and TKA patients. Methods: A single-centre retrospective cohort study of patients admitted to our hospital over the course of 6 weeks from September to October 2021 for a THA or TKA. All patients who underwent elective THA/TKA were included, and trauma cases were excluded. Results: Ninety-two consecutive patients were included in this study. The overall rate of POUR was 17%. A shorter operative duration resulted in a reduced risk of POUR (median duration of non-retention patients, 88 min vs. 100 min POUR patients; odds ratio, 0.97; 95% CI, 0.95-0.99, p = 0.018). The median bladder volume of patients with urinary retention at the point of diagnosis was 614 mL (range, 298-999 mL). The arthroplasty type, anaesthetic technique, pre-operative morphine use, body mass index, age, cardiovascular disease, and renal disease were found to have no significant association with POUR. Conclusions: A reduced operative time of arthroplasty surgery is associated with a decreased risk of POUR. Patients with a prolonged operative time should have an increased frequency of micturition monitoring in the immediate post-operative period.

The effect of virtual rainforest and a white noise mobile application on satisfaction, tolerance, comfort, and vital signs during arthroscopy

BACKGROUND AND PURPOSE

This study was conducted to investigate the effect of Virtual Rainforest (VRF) and a White Noise (WN) mobile applications on patient satisfaction, tolerance, comfort, and vital signs during arthroscopic knee surgery.

METHODS

This is a randomized, controlled, interventional study. The study was completed with a total of 93 participants, 31 in the VRF group, 31 in the WN group, and 31 in the control group. Data were collected using a Patient Information Form and a Visual Analog Scale for satisfaction, tolerance, and comfort.

RESULTS

The results of study showed that there were significant increases in tolerance, satisfaction, comfort, respiratory rate, and oxygen saturation levels and significant decreases in heart rate, systolic and diastolic blood pressures in both VRF and WN groups (p < .05). In the control group, no significant difference was found between the means of the variables before and after the procedure (p > .05).

CONCLUSION

According to the results of the study, VRF and WN applied during the arthroscopy procedure increased satisfaction, tolerance, and comfort in patients and had a positive effect on vital signs.

TRIAL AND PROTOCOL REGISTRATION

ClinicalTrials.gov, NCT05992714.

Thoracic spinal anesthesia with intrathecal sedation for lower back surgery: a retrospective cohort study

Background

Spinal anesthesia (SA) is a good alternative to general anesthesia (GA) for spine surgery. Despite that, a few case series concern the use of thoracic spinal anesthesia for short-duration surgical interventions. In search of an alternative approach to GA and a better opioid-free modality, we aimed to investigate the safety, feasibility, and patient satisfaction of thoracic SA for spine surgery.

Materials and methods

We analyzed retrospectively a cohort of 24 patients operated on for a degenerative and osteoporotic pathology of the lower thoracic and lumbar spine. Data was collected from medical records, including clinical notes, operative and anesthesia records, and patient questionnaires.

Results

Twenty-one surgeries for herniated discs, two for degenerative spinal stenosis, and one for multi-level osteoporotic vertebral body fractures were performed under spinal anesthesia with intrathecal sedation. In all cases, we applied 0.5% isobaric bupivacaine and the following adjuvants: midazolam, clonidine or dexmedetomidine, and dexamethasone. We boosted the anesthesia with local ropivacaine due to inefficient sensory block in two patients. Nobody in the cohort received intravenous opioids, non-steroidal anti-inflammatory drugs, or additional sedation intraoperatively. Postoperative painkillers were upon the patient's request. No significant complications were detected.

Conclusion

Thoracic spinal anesthesia incorporating adjuvants such as midazolam, clonidine or dexmedetomidine, and dexamethasone demonstrates not only efficient conditions for spine surgery, a favorable safety profile, high patient satisfaction, and intrathecal sedation but also effective opioid-free pain management.

Comparison of Postoperative Analgesia Between Intrathecal Nalbuphine and Intrathecal Fentanyl in Infraumbilical Surgeries: A Double-Blind Randomized Controlled Trial

INTRODUCTION

Spinal anesthesia is a widely used regional anesthesia technique for surgeries below the umbilicus, but postoperative analgesia is of major concern due to the relatively short duration of the local anesthetic. Various drugs were used as an additive to local anesthetic to prolong the duration of postoperative analgesia. This study aims to compare the efficacy of nalbuphine and fentanyl as an intrathecal additive along with local anesthetic.

METHODOLOGY

A total of 166 patients aged between 18 and 65 years belonging to the American Society of Anesthesiologists (ASA) I and II undergoing elective infraumbilical surgeries were included in the prospective double-blind randomized controlled trial. The patients were allocated into two groups of 83 each. Group N was given 2.5 mL of 0.5% bupivacaine + 1 mg of nalbuphine (0.5 mL), and group F received 2.5 mL of 0.5% bupivacaine + 25 mcg fentanyl (0.5 mL). Both groups were compared for postoperative analgesia, onset and duration of both sensory and motor blockade, intraoperative hemodynamics, and side effects.

RESULTS

All demographic data, hemodynamic parameters, and side effects were not statistically significant among the two groups. However, other parameters, such as the mean duration of analgesia, which was 267.27 ± 172.099 minutes in group N and 161.35 ± 14.957 minutes in group F; meantime for the onset of sensory blockade, which was 3.94 ± 1.769 minutes in group N and 5.94 ± 0.929 minutes in group F; onset of complete motor blockade, which was 7.10 ± 1.858 minutes in group N and 11.61 ± 1.218 minutes in group F; duration of motor blockade, which was 182.57 ± 13.011 minutes in group N and 112.53 ± 7.389 minutes in group F; and mean time taken for two-segment regression, which was 118.20 ± 12.61 minutes in group N and 113.72 ± 8.84 minutes in group F, were all comparable between the two groups.

CONCLUSION

Nalbuphine was found to be more efficacious for prolongation of postoperative analgesia with better hemodynamic stability.

Factors Influencing Patient Preference for Anesthesia in Ambulatory Hand Surgery

BACKGROUND

The purpose of this study was to identify factors that influence preoperative patient preferences toward anesthesia in patients in a hand and upper extremity clinic.

METHODS

A survey was administered to consecutive patients in a hand and upper extremity orthopedic clinic at an urban tertiary academic institution. The survey addressed presenting clinical complaint, anesthesia preference for minor soft tissue hand and wrist procedures, factors influencing anesthesia preference, and patient history of anesthesia and surgical treatment. The primary outcome measure was anesthesia preference: local-only or local with sedation.

RESULTS

Surveys were completed by 219 patients over a 1-month period with a mean patient age of 55 years. Most patients presented with a hand/wrist complaint (56%). One hundred fifty-two patients (71%) preferred local anesthesia with sedation and 61 patients (29%) preferred local-only anesthesia. Patients who preferred local-only anesthesia reported being more likely to be influenced by surgeon preference and cost, and also were more likely to have had prior experience with local-only anesthesia. In contrast, patients who preferred local anesthesia with sedation were more likely to be concerned about pain or were nervous about surgery. Prior surgical experience did not influence preference for anesthesia.

CONCLUSION

Patient preferences for local-only anesthesia versus local anesthesia with sedation for ambulatory hand surgery are mixed, with most patients preferring sedation. Understanding patient preferences for anesthesia can better inform preoperative discussions and shared decision-making in anesthesia choice.

Postoperative complications of spinal vs general anesthesia in elderly patients undergoing hip hemiarthroplasty

INTRODUCTION

Elderly patients with hip fractures are at high risk for mortality due to postsurgical complications. Hip hemiarthroplasty is a routine procedure done in elderly patients for surgical repair  of femoral neck fractures. Both general and spinal anesthesia can be used in elderly patients undergoing hemiarthroplasty. Rates of postoperative complications among the two anesthetic choices have not been directly compared. In this study, we compare the rates of postoperative complications in elderly patients (age greater than 70) undergoing hip hemiarthroplasty for femoral neck fractures using a national database.

METHODS

Data for the years 2015-2020 from the National Surgical Quality Improvement Program (NSQIP) were used for the study. Patients greater than 70 years of age who received a hip hemiarthroplasty with general anesthesia or spinal anesthesia were identified using CPT procedure codes. Pertinent preoperative variables and rates of postoperative complications were characterized and analyzed.

RESULTS

Our study found that elderly patients who received spinal anesthesia had, on average, longer length of stays but shorter operative times compared to patients who received general anesthesia. Furthermore, we found that patients who received spinal anesthesia had lower rates of systemic sepsis, cardiac arrests, and blood transfusions when compared to patients who received general anesthesia. Finally, we found that overall rates of mortality were significantly lower in the spinal anesthesia cohort compared to the general anesthesia cohort.

CONCLUSION

Our work suggests that patients who underwent spinal anesthesia for hip arthroplasty may have lower rates of postoperative complications. This work further highlights the role of anesthetic choice in preventing complications following hip hemiarthroplasty procedures.

There remains a role for neuraxial anesthesia for hip fracture surgery in the post-REGAIN era

Two recent, large-scale, randomized controlled trials comparing neuraxial anesthesia with general anesthesia for patients undergoing surgical fixation of a hip fracture have sparked interest in the comparison of general and neuraxial anesthesia. These studies both reported non-superiority between general and neuraxial anesthesia in this patient cohort, yet they have limitations, like their sample size and use of composite outcomes. We worry that that if there is a perception among surgeons, nurses, patients and anesthesiologists that general and spinal anesthesia are equivalent (which is not what the authors of the studies conclude), it may become difficult to argue for the resources and training to provide neuraxial anesthesia to this patient population. In this daring discourse, we argue that despite the recent trials, there remain benefits of neuraxial anesthesia for patients who have suffered hip fractures and that abandoning offering neuraxial anesthesia to these patients would be an error.

Awake Spinal Fusion Is Associated with Reduced Length of Stay, Opioid Use, and Time to Ambulation Compared to General Anesthesia: A Matched Cohort Study

OBJECTIVE

There is increasing interest in performing awake spinal fusion under spinal anesthesia (SA). Evidence supporting SA has been positive, albeit limited. The authors set out to investigate the effects of SA versus general anesthesia (GA) for spinal fusion procedures on length of stay (LOS), opioid use, time to ambulation (TTA), and procedure duration.

METHODS

The authors performed a retrospective review of a single surgeon's patients who underwent lumbar fusions under SA versus GA from June of 2020 to June of 2022. SA patients were compared to demographically matched GA counterparts undergoing comparable procedures. Analyzed outcomes include operative time, opioid usage in morphine milligram equivalents, TTA, and LOS.

RESULTS

Ten SA patients were matched to 10 GA counterparts. The cohort had a mean age of 66.77, a mean body mass index of 27.73 kg/m2, and a median American Society of Anesthesiologists Physical Status Score of 3.00. LOS was lower in SA versus GA patients (12.87 vs. 50.79 hours, P = 0.001). Opioid utilization was reduced in SA versus GA patients (10.76 vs. 31.43 morphine milligram equivalents, P = 0.006). TTA was reduced in SA versus GA patients (7.22 vs. 29.87 hours, P = 0.022). Procedure duration was not significantly reduced in SA patients compared to GA patients (139.3 vs. 188.2 minutes, P = 0.089).

CONCLUSIONS

These preliminary retrospective results suggest the use of SA rather than GA for lumbar fusions is associated with reduced hospital LOS, reduced opioid utilization, and reduced TTA. Future randomized prospective studies are warranted to determine if SA usage truly leads to these beneficial outcomes.

Assessing the Precision of Surgery Duration Estimation: A Retrospective Study

Background and Objectives

The operating room (OR) is considered the highest source of cost and earnings. Therefore, measuring OR efficiency, which means how time and resources are allocated precisely for their intended purposes in the operating room is crucial. Both overestimation and underestimation negatively impact OR efficiency Therefore, hospitals defined metrics to Measuring OR Effeciency. Many studies have discussed OR efficiency and how surgery scheduling accuracy plays a vital role in increasing OR efficiency. This study aims to evaluate OR efficiency using surgery duration accuracy.

Methods

This retrospective, quantitative study was conducted at King Abdulaziz Medical City. We extracted data on 97,397 surgeries from 2017 to 2021 from the OR database. The accuracy of surgery duration was identified by calculating the duration of each surgery in minutes by subtracting the time of leaving the OR from the time of entering the OR. Based on the scheduled duration, the calculated durations were categorized as either underestimation or overestimation. Descriptive and bivariate analyses (Chi-square test) were performed using the Statistical Package for the Social Sciences (SPSS) software.

Results

Sixty percent out of the 97,397 surgeries performed were overestimated compared to the time scheduled by the surgeons. Patient characteristics, surgical division, and anesthesia type showed statistically significant differences (p <0.05) in their OR estimation.

Conclusion

Significant proportion of procedures have overestimated. This finding provides insight into the need for improvement.

Recommendations

It is recommended to enhance the surgical scheduling method using machine learning (ML) models to include patient characteristics, department, anesthesia type, and even the performing surgeon increases the accuracy of duration estimation. Then, evaluate the performance of an ML model in future studies.

Does the type of anesthesia (regional vs. general) represent an independent predictor for in-hospital complications in operatively treated malleolar fractures? A retrospective analysis of 5262 patients

PURPOSE

The impact of the type of anesthesia (regional vs. general anesthesia) on in-hospital complications in ankle fractures has not been thoroughly studied yet. Identifying factors that place patients at risk for complications following ankle fractures may help reduce their occurrence. The primary goal of this study was (1) to describe the cohort of patients and (2) to evaluate independent risk factors for complications during hospitalization.

METHODS

We analyzed patients from 2005 to 2019 with an operatively treated isolated fracture of the medial or lateral malleolus using a prospective national quality measurement database. Patients were selected based on international classifications (ICD) and national procedural codes (CHOP). Uni- and multivariate analysis were applied.

RESULTS

In total, we analyzed 5262 patients who suffered a fracture of the malleolus; 3003 patients (57%) had regional and 2259 (43%) general anesthesia. Patients with regional anesthesia were significantly older (51 vs. 46 years), but healthier (23 vs. 28% comorbidities) than patients who received general anesthesia. The in-hospital complication rate was not significantly lower in regional anesthesia (2.2% vs 3.0%). The type of anesthesia was not an independent predictor for complications while controlling for confounders.

CONCLUSION

Type of anesthesia was not an independent predictor of complications; however, higher ASA class, age over 70 years, fracture of the medial versus lateral malleolus, longer preoperative stay, and duration of surgery were significant predictors of complications. Patient and procedure characteristics, as well as changes in medical care and epidemiological changes along with patient requests, influenced the choice of the type of anesthesia.

A Study of the Clinical Effects of Sequential Combined Spinal Epidural Anesthesia and Spinal Anesthesia in Patients Undergoing Orthopedic Surgeries

BACKGROUND

In orthopedic surgeries, there has been an increase in the usage of the neuraxial blockade to provide excellent surgical conditions and prolonged postoperative analgesia. The introduction of the sequential combined spinal epidural anesthesia (SCSEA) technique provides benefits for both spinal anesthesia (SA) and epidural anesthesia. The focus of this study was to analyze the time needed to attain a desired level of sensory block, to compare the period of sensory block, and to study the intraoperative hemodynamics in the SCSEA and SA groups.

MATERIALS AND METHODS

The study was conducted on patients admitted for elective lower limb orthopedic surgeries. The sample size for this prospective randomized study is two groups of 67 subjects each. Patients aged between 18 and 65 years, posted for orthopedic surgeries for two to three hours, and of American Society of Anaesthesiologists (ASA) Grades 1 and 2 were included and divided into two groups. Group A patients received SCSEA with an epidural-test dose of 3 ml lignocaine (2%) with adrenaline and spinal bupivacaine (0.5%) of 1.5 ml-7.5 mg + fentanyl .25 mic if the sensory level was below T8. An epidural top-up was given with 2 ml per segment of 0.5% bupivacaine to bring the sensory level to T8. Group B patients received SA with spinal bupivacaine (0.5%) of 3 ml-15 mg + fentanyl .25 mic. Intraoperative hemodynamics, the duration to achieve a sensory level of T8, the time for two-segment regression of sensory block, and the complications that occurred were recorded.

RESULTS

The study included a total of 134 subjects with each group having 67 subjects admitted for lower limb surgery. The mean value (SD) of the time taken to attain sensory block in the SCSEA group was prolonged when compared to the SA group (7.15 ± 0.75 and 5.01 ± 0.88). The time for two-segment regression in the SCSEA group was 86.77 ± 3.60 and the SA group was 106.4 ± 8.01, which indicated that the SA group has a longer and better sensory block. Substantially, the study shows that the SCSEA group (P < 0.05) has better hemodynamics when compared to the SA group.

CONCLUSION

The SCSEA technique has better intraoperative hemodynamic stability with a longer analgesic effect when compared to SA. SA shows a sudden change in hemodynamics but reveals a greater sensory block.

Impact of Anesthetic Choice on Time to Discharge for Same-Day Discharge Joints

INTRODUCTION

As total joint arthroplasty programs continue to move towards same-day discharge (SDD), time to discharge is an increasingly important performance indicator. The primary objective of this study was to determine the impact of the choice of anesthetic on the time to discharge after SDD primary hip and knee arthroplasty.

METHODS

A retrospective chart review was conducted within our SDD arthroplasty program, with 261 patients identified for analysis. Baseline characteristics, length of surgery, anesthetic drug, dose, and perioperative complications were extracted and recorded. The time from the patient leaving the operating room (OR) to physiotherapy (PT) assessment, and from OR to discharge were recorded. These were referred to as ambulation time and discharge time respectively.

RESULTS

The ambulation time was significantly reduced when hypobaric lidocaine was used in a spinal block compared to isobaric or hyperbaric bupivacaine-135 minutes (range, 39 to 286), 305 minutes (range, 46 to 591), 227 minutes (range, 77 to 387) respectively-p<0.0001). Similarly, the discharge time was also significantly lower with hypobaric lidocaine compared to isobaric bupivacaine, hyperbaric bupivacaine, and general anesthesia-276 minutes (range, 179 to 461), 426 minutes (range, 267 to 623), 375 minutes (range, 221 to 511), 371 minutes (range, 217 to 570) respectively-(p<0.0001). No cases of transient neurologic symptoms were reported.

CONCLUSIONS

Patients receiving a hypobaric lidocaine spinal block experienced significantly reduced ambulation time and time to discharge compared to other anesthetics. Surgical teams should feel confident in using hypobaric lidocaine during spinal anesthesia as it is quick and efficacious.

Patient Concerns About Wide-Awake Local Anesthesia No Tourniquet (WALANT) Hand Surgery

PURPOSE

Wide-Awake Local Anesthetic No Tourniquet (WALANT) hand surgery avoids many medical risks associated with traditional anesthesia options. However, patients may be hesitant to choose the WALANT approach because of concerns about being awake during surgery. The purpose of this study was to characterize patients' thoughts and concerns about being awake during hand surgery and determine factors that may affect their decision about anesthesia options.

METHODS

Qualitative interviews were conducted with 15 patients with a diagnosis of carpal tunnel syndrome, trigger finger, or De Quervain's tenosynovitis who were receiving nonoperative care. Interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was used to identify themes, concerns, and potential intervention targets.

RESULTS

Eight participants reported that patients have a general bias against being "knocked out," 7 of whom described concerns of uncertainty about emerging from anesthesia. All participants would consider WALANT, with some reservations. Recurrent themes included ensuring they would not feel, see, or hear the surgery and a preference toward distractions, such as music or engaging conversation. Of 15 participants, 13 would not want to see the surgery. For patients who found WALANT appealing, they valued the decreased time investment compared to sedation and the avoidance of side effects or exacerbation of comorbidities. A recurring theme of trust between surgeon and patient arose when deciding about anesthesia type.

CONCLUSIONS

Most patients are open to WALANT, but have concerns of hearing the surgery or feeling pain. Potential interventions to address these concerns, beyond establishing a trusting physician-patient relationship, include music or video with headphones and confirming skin numbness prior to surgery.

CLINICAL RELEVANCE

This study provides insights into patients' thought processes regarding WALANT hand surgery and give the surgeon talking points when counseling patients on their anesthesia type for hand surgery.

Anoplasty for anatomical anal stenosis: systematic review of complications and recurrences

AIM

The optimal surgical treatment for anatomical anal stenosis (AS) remains to be determined. The aim of this study was to determine the rates of complications and recurrence after anoplasty for anatomical AS and, wherever feasible, compare the outcomes for the various techniques.

METHOD

A PROSPERO-registered systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, PubMed, Embase, Cochrane Library of Systematic Review, Scopus and Web of Science were searched for articles published up to May 2021. Studies that assessed the outcomes of anoplasty in adult patients with anatomical AS were selected. The primary outcomes were complications and recurrence. The methodological quality of studies was appraised using the Joanna Briggs Institute critical appraisal tools.

RESULTS

From the total of 2705 unique screened records, 151 were assessed for eligibility. Only 29 studies (two prospective) met the inclusion criteria, reporting data on 556 patients [mean age 53 (18-83) years, 46% female]. Previous history of surgery for haemorrhoidal disease accounted for three quarters of cases. A total of 14 types of anoplasty were found, with the Y-V flap being the most performed technique [27% of cases (n = 149)]. Complications frequently occurred, with a pooled prevalence of 10.2% (95% CI 3.9%-24.1%) after Y-V flap and 11.5% (5.3%-23.0%) after rhomboid/diamond flap. Patients undergoing house flap achieved better results in terms of clinical improvement, satisfaction and quality of life compared with Y-V flap and rhomboid/diamond flap. When considering only studies with at least 12 months of follow-up, the pooled prevalence of recurrence was 4.7% (2.2%-9.8%), with significantly higher rates observed in the prospective versus retrospective series [pooled prevalence 18.9% (11.5%-29.5%) vs. 3.6% (1.7-7.8%), respectively; p < 0.001].

CONCLUSION

Both complications and recurrence were significantly lower after house flap compared with rhomboid/diamond and Y-V flap. Better designed multicentre studies with longer follow-up are needed to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42021239493.

Analgesic efficacy of local versus proximal nerve blocks after hallux valgus surgery: a systematic review

Background

Hallux valgus (HV) surgery is an orthopaedic procedure that commonly causes mild to moderate postoperative pain. Effective management of this pain has become an important element of modern hallux valgus surgical treatment. A local anaesthetic (LA) with an antinociceptive effect can control this pain. However, relatively few papers have evaluated this strategy in depth. The objective of the current systematic review was to address this demand by comparing the efficacy of proximal and local blocks in controlling postoperative pain following hallux valgus surgery.

Main text

Ovid-MEDLINE, Cochrane Central, PubMed, Web of Science (WOS), Scopus, and Embase were searched from their inceptions through December 29, 2021. Observational and clinical trial publications in peer-reviewed English-language journals with a sample size of at least 20 were included. The trials involved adults over 18 who could describe their discomfort and had a bunionectomy. The included studies were evaluated using the Cochrane risk of bias 2 method. Descriptive analysis synthesised the results.

Among the 439 articles identified, five studies compromising 459 participants were included. Ankle blocks were superior to control in two studies (P = 0.001, P < 0.001) and superior to local blocks in one study (P < 0.001). Additionally, one study showed that popliteal and ankle blocks administered with lidocaine or levobupivacaine were equivalent (P = 0.123 and P = 0.055, respectively). However, one of these five included studies indicated that ankle blocks were not effective (P = 0.123) in reducing postoperative pain.

Conclusions

The key findings presented herein suggest that regional blocks effectively reduce postoperative pain and that an ankle block has more supportive evidence for its effectiveness. However, an adequate assessment of the effectiveness of various administrative routes was challenging due to the lack of reliable evidence. This needs to be addressed in future studies.

Trial registration

PROSPERO registration: CRD42022307974.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00581-0.

Regional versus general anesthesia for ambulatory total hip and knee arthroplasty

PURPOSE OF REVIEW

With the removal of both total knee and total hip arthroplasty from the Centers for Medicare and Medicaid Services' inpatient-only list, efforts to improve efficiency of the perioperative management of total joint patients have increased recently. The publication of several recent studies examining the impact of anesthesia type on outcomes has prompted the need to review the overall state of evidence for spinal versus general anesthesia for outpatient total joint arthroplasty.

RECENT FINDINGS

Overall complication rates are low in this carefully selected patient population. The majority of patients who are preselected for outpatient total joint arthroplasty appear to successfully achieve this outcome. Some retrospective studies have suggested a benefit for spinal anesthesia in terms of same-day discharge success but direct comparisons in prospective studies are lacking.

SUMMARY

The type of anesthesia used for total joint arthroplasty may have an important effect on outcomes. Until randomized control trials are performed we must rely on existing evidence, which suggests that both spinal and general anesthesia can lead to successful outcomes after ambulatory total joint arthroplasty.

Adoption of awake spine surgery - trends from a national registry over 14 years

BACKGROUND CONTEXT

Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied.

PURPOSE

To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States.

STUDY DESIGN/SETTING

A retrospective observational study.

PATIENT SAMPLE

Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019.

OUTCOME MEASURES

The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019.

METHODS

Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006.

RESULTS

We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m²; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively).

CONCLUSIONS

Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery.

SPINAL ANESTHESIA IN DAY SURGERY - EARLY EXPERIENCES

Day surgery is a term that refers to performing an operation under anesthesia without needing to stay in the hospital for more than 24 hours. Day surgery has many advantages over surgery that involves a multiple-day hospital stay. Anesthesia for day surgery must have a rapid onset of action, a rapid cessation of action, and be free of, or have minimal side effects. For many years, general anesthesia was believed to be the anesthesia of choice for day surgery due to the delayed onset of local anesthetic after spinal anesthesia, a much longer duration of motor function recovery after surgery with spinal anesthesia compared to general anesthesia, and a more frequent incidence of side effects with spinal anesthesia, such as urinary retention or post-puncture headache. However, with the discovery of new, shorter-acting local anesthetics, and the use of smaller-diameter spinal needles, spinal anesthesia is becoming an equivalent anesthetic option for day surgery, if not a better one. Our early expiriences with spinal anesthesia in day surgery are excellent.

Dose Selection of Ropivacaine for Spinal Anesthesia in Elderly Patients with Hip Fracture: An Up-Down Sequential Allocation Study

Objective

The dose selection of ropivacaine for spinal anesthesia in clinical work mainly depends on the experience of the anesthesiologist. In this study, a prospective and modified up-down sequential allocation design was used to provide the optimal dose selection of ropivacaine for spinal anesthesia.

Patients and methods

This study was divided into two stages, and a total of 164 elderly patients with elective hip fractures were included. In stage I, the dose of ropivacaine was selected using the up-down sequential method of height correction, and the 50% effective dose (ED50) and 95% effective dose (ED95) were obtained. A nomogram for predicting satisfactory anesthesia and a formula for predicting the optimal dose was also given in this stage. In stage II, the dose of ropivacaine was calculated by using the optimal dose prediction formula, so as to evaluate the efficacy and safety of the model.

Results

The ED50 and ED95 of the stage I were 7.036 mg (95%CI 6.549–7.585 mg) and 8.709 mg (95%CI 7.902–14.275 mg), respectively. And provided a nomogram predicting satisfactory anesthesia with a C-index of 0.847 (95%CI 0.774–0.92). The optimal dose prediction formula of ropivacaine was calculated, including variables for age, gender, height, and weight. This formula was found to be 90% efficient. It is worth mentioning that the incidence of direct transfer to the ward in the two stages was as high as 86.84% and 93.33%, respectively, and no patients were transferred to the ICU in stage II.

Conclusion

The ED50 and ED95 of ropivacaine were 7.036 mg and 8.709 mg, respectively, and the nomograms are sufficiently accurate to predict satisfactory anesthesia. Beyond that, the dose prediction equation provided in this study has high efficacy and safety, and can guide the dose selection of spinal anesthesia in elderly patients with hip fracture in clinical practice.

Clinical trials registration

ChiCTR2100046982

Influence of height on ED95 of intrathecal 2-chloroprocaine for knee arthroscopy: A prospective dose-response clinical trial

BACKGROUND

Plain 2-chloroprocaine , a rapid acting amino-ester-type local anaesthetic, is used in short ambulatory procedures under spinal anaesthesia. The ED 95 of 2-chloroprocaine for lower limb surgery has not yet been defined. Moreover, patients' body height could influence the effects of the administered dose.

OBJECTIVES

The aim of this study was to determine the ED 95 of plain 2-chloroprocaine based on the height of patients undergoing ambulatory knee arthroscopy under spinal anaesthesia using the continual reassessment statistical method (CRM).

DESIGN

Prospective, dose-response, double blind, controlled, bi-center, clinical trial.

SETTING

One university teaching hospital in Brussels and one general teaching hospital, Braine l'Alleud, Belgium. Université libre de Bruxelles.

PATIENTS

ASA I-III (120 patients) scheduled for day-case knee arthroscopy under spinal anaesthesia.

INTERVENTIONS

Patients were divided into three groups of 40, each comprising 10 cohorts of 4 patients, according to their respective heights (Group 1: 150-165 cm, Group 2: 166-180 cm, Group 3: 181-195 cm). Each patient enrolled into one of the 3 groups received an intrathecal dose of plain 2-chloroprocaine determined by the CRM. The starting doses for the first cohorts of four were 40 mg in group 1, 45 mg in group 2 and 50 mg in group 3. The doses for subsequent cohorts were determined by CRM of outcomes in all patients in the previous competed cohorts. Anaesthesia was considered successful when there was a lack of pinprick or cold sensation up to T12, the visual analogue scale score for tourniquet pain was < 2 and no pain during surgery.

MAIN OUTCOMES

The primary outcome was the success or failure of the block. Side effects were also recorded.

RESULTS

ED 95 of 2-chloroprocaine is 40 mg in group 1, 35 mg in group 2, 45 mg in group 3. Groups were different in terms of height and gender ( P  < 0.05) and similar in terms of body mass index and age ( P  > 0.05).

CONCLUSION

The ED95 of intrathecal 2-chloroprocaine for patients undergoing ambulatory knee arthroscopy is between 35 and 45 mg. Height could be a factor involved in the calculation, and patient sex could partly explain the nonlinear relation between height and dose.

TRIAL REGISTRY NUMBER

Clinicaltrials.gov NCT03882489.

Take-Home Video Shortens the Time to First Ambulation in Patients With Inguinal Hernia Repair Under General Anesthesia: A Retrospective Observational Study

Background

Data on the relationship between take-home video and the time to first ambulation remains scant. Here, we aimed to investigate whether viewed take-home video during pre-hospitalization is independently associated with the time to first ambulation in postoperative patients with inguinal hernia repair under general anesthesia.

Methods

We retrospectively reviewed and analyzed the relationship between viewed take-home video and the time to first ambulation between September 2020 and October 2021.The independent t-tests or Mann-Whitney U-tests was used to compare the means of two groups (viewed take-home video and non-viewed take-home video). Chi-square test was used to compare the rates between the two groups. We used a linear regression model to see if there was a difference between exposure and outcome variable. Both models were used to observe the effect size of the exposed variable. Subgroup analysis was employed to assess the impact of various factors.

Results

This study included a total of 120 patients with inguinal hernia repair under general anesthesia following day surgery. The average age of the participants in the two groups was 43.16 and 44.83 years, respectively, and about 82.5% of the patients were male. Our fully adjusted linear regression results showed that individuals in the viewed video group were associated with a decreased time to first ambulation (h) after adjusting for confounders (β = −0.50, 95%CI: −0.83, −0.17; P = 0.004). In addition, the linear regression analysis of the relationship between viewed video and length of stay showed that β = −2.10 (95%CI:CI: −3.85, −0.34; P = 0.021). Similarly, subgroup analysis yielded similar results for the viewed video group patients compared to those in the non-viewed video group.

Conclusion

Taken together, our findings demonstrated that viewed video could shorten the time to first ambulation, which in turn reduce the length of stay in postoperative patients under general anesthesia.

The Association between General Anesthesia and New Postoperative Uses of Sedative-Hypnotics: A Nationwide Matched Cohort Study

Sedative−hypnotic misuse is associated with psychiatric diseases and overdose deaths. It remains uncertain whether types of anesthesia affect the occurrence of new postoperative uses of sedative−hypnotics (NPUSH). We used reimbursement claims data of Taiwan’s National Health Insurance and conducted propensity score matching to compare the risk of NPUSH between general and neuraxial anesthesia among surgical patients who had no prescription of oral sedative−hypnotics or diagnosis of sleep disorders within the 12 months before surgery. The primary outcome was NPUSH within 180 days after surgery. Multivariable logistic regression models were used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI). A total of 92,222 patients were evaluated after matching. Among them, 15,016 (16.3%) had NPUSH, and 2183 (4.7%) were made a concomitant diagnosis of sleep disorders. General anesthesia was significantly associated both with NPUSH (aOR: 1.17, 95% CI: 1.13−1.22, p < 0.0001) and NPUSH with sleep disorders (aOR: 1.11, 95% CI: 1.02−1.21, p = 0.0212) compared with neuraxial anesthesia. General anesthesia was also linked to NPUSH that occurred 90−180 days after surgery (aOR: 1.12, 95% CI: 1.06−1.19, p = 0.0002). Other risk factors for NPUSH were older age, female, lower insurance premium, orthopedic surgery, specific coexisting diseases (e.g., anxiety disorder), concurrent medications (e.g., systemic steroids), postoperative complications, perioperative blood transfusions, and admission to an intensive care unit. Patients undergoing general anesthesia had an increased risk of NPUSH compared with neuraxial anesthesia. This finding may provide an implication in risk stratification and prevention for sedative−hypnotic dependence after surgery.

High turnover for ambulatory orthopedic surgery

PURPOSE OF REVIEW

The trend in the perioperative management of patients having orthopedic surgery in the ambulatory setting emphasizes time-efficiency and rapid turnovers. Anesthetic techniques and management continue to evolve to increase efficiency and decrease time spent in recovery.

RECENT FINDINGS

Minimizing time patients spend in phase 1 recovery or bypassing phase 1 altogether, known as fast-tracking, has become an important goal in containing costs in high turnover, ambulatory settings. Anesthetic techniques, particularly implementation of regional anesthesia and multimodal analgesia, have evolved to maximize efficiency.

SUMMARY

Anesthetic goals in the setting of high-turnover orthopedic surgery include effective multimodal analgesia, decreasing monotherapy with opioids, and patient education. Regional anesthesia as part of a multimodal analgesic regimen is increasingly used in ambulatory surgery fast-tracking protocols.

General Versus Regional Anaesthesia for Lower Limb Arthroplasty and Associated Patient Satisfaction Levels: A Prospective Service Evaluation in the Oxford University Hospitals

Introduction

Lower limb arthroplasty is performed under general anaesthesia (GA) or regional anaesthesia (RA). There is increasing evidence of the surgical and anaesthetic benefits of RA. National Institute for Health and Care Excellence (NICE) guidelines advise using either but highlight a lack of data comparing outcomes of RA and GA for these procedures. We conducted a service evaluation, prospectively analysing elective orthopaedic cases performed at the Nuffield Orthopaedic Centre, Oxford, UK from 19/11/2018 to 03/04/2019. We aimed to compare data on anaesthetic assessment, intra-operative parameters and patient satisfaction for RA and GA cases.

Methods

We selected elective patients, aged above 18, undergoing total hip, total knee or unilateral knee arthroplasties. Prospective quantitative and qualitative data were collected using two forms. Firstly, anaesthetists completed a case report recording demographic data, intra-operative details and reason for anaesthetic choice. Secondly a questionnaire gathered patient satisfaction data. This was analysed using descriptive statistics and presented in tables.

Results

Data for 132 patients were collected over the service evaluation period. After exclusion, 99 patients were included for final analysis; 59 underwent GA and 40 had RA. GA was used predominantly due to patient preference (74.6%). RA was used primarily due to anaesthetic preference (75%); most commonly due to speed of list and duration of operation. Overall patients had low pain scores (0.3/10) and high pre-operative anxiety levels (4.6/10) regardless of anaesthetic.

Conclusion

Our results show high patient satisfaction with GA and RA for lower limb arthroplasty; however, pre-operative anxiety was common for both. Patient preference and comfort influenced choice of anaesthesia, highlighting the importance of pre-operative counselling and education to facilitate shared decision making, leading to favourable post-operative outcomes.

Anesthetic Technique (Spinal vs. General Anesthesia) in Holmium Laser Enucleation of the Prostate: Retrospective Analysis of Procedural and Functional Outcomes among 1,159 Patients

OBJECTIVE

The aim of the study was to compare procedural efficacy, early and late functional outcomes in holmium laser enucleation of the prostate (HoLEP) under spinal anesthesia (SA) versus general anesthesia (GA).

METHODS

We retrospectively reviewed patients undergoing HoLEP at our institution between 2012 and 2017. Standard pre-, peri-, and postoperative characteristics were compared according to anesthetic technique. Multivariable logistic regression analyses (MVAs) were employed to study the impact of SA on procedural efficacy and postoperative complications.

RESULTS

Our study cohort consisted of 1,159 patients, of whom 374 (32%) underwent HoLEP under SA. While a medical history of any anticoagulation/antiplatelet therapy except low-dose acetylsalicylic acid was significantly more common among patients undergoing GA (16% vs. 10%, p = 0.001), no other significant differences in preoperative characteristics were noted including age, body mass index, American Society of Anesthesiologists Classification (ASA), prostate size, or International Prostate Symptom Score (IPSS), and quality of life scores. Patients under SA exhibited shorter times of enucleation 42 min (interquartile range [IQR]:27-59 vs. 45 min [IQR: 31-68], p = 0.002), and combined time of enucleation/morcellation/coagulation (57 min [IQR: 38-85] vs. 64 min [IQR: 43-93], p = 0.002), as well as fewer complications (Clavien-Dindo ≥3) (12 [3.2%] vs. 55 [7%], p = 0.013). These associations were confirmed in MVA. Patients did not differ significantly with regard to early micturition including post-void residual volume and maximum flow-rate improvement. At a median follow-up of 33 months (IQR: 32-44), patients with SA had a lower IPSS score (median 3 [IQR: 1-6] vs. 4 [IQR: 2-7], p = 0.039). However, no significant differences were observed with respect to any urinary incontinence, urge symptoms, and postoperative pain.

CONCLUSION

In this large retrospective series, HoLEP under SA was a safe and efficacious procedure with comparable early and long-term functional outcomes.

Delivering Essential Surgical Care for Lower-limb Musculoskeletal disorders in the Low-Resource Setting

Background

Mismatched surgeon-anesthesiologist ratios often exist in low-resource settings making safe emergency essential surgical care challenging. This study is an audit of emergency essential procedures performed for lower-limb (LL) musculoskeletal disorders (MSD) when an anesthesiologist was unavailable. It aims to identify strategies for safe anesthesia.

Methods

A 5-year retrospective audit of emergency essential LL orthopedic procedures performed at remote mission hospital in Central India was performed. Out of necessity, a regional anesthesia (RA) protocol was developed in collaboration with anesthesiologists familiar with the setting. The incidence of intraoperative surgical and perioperative anesthesia complications when RA was administered by a surgeon was evaluated.

Results

During this period, 766 emergency essential LL MSDs procedures were performed. An anesthesiologist was available for only 6/766. RA was administered by a surgeon for 283/766. This included spinal anesthesia (SA) for 267/283 patients, peripheral nerve blocks for 16/283. Local infiltration and/or sedation was administered to 477/766. There were 17 intraoperative surgical complications. Anesthesia-related complications included 37/267 patients who required multiple attempts to localize subarachnoid space and SA failure in 9/267 patients all of whom had successful re-administration. Additional sedation and infiltration of local anesthetic was required in 5/267 patients.

Conclusion

Remote pre-anesthesia consultation for high-risk patients, local surgeon-anesthesiologist networking, protocol-guided management, and dedicated short duration of training in anesthesia may be considered as an alternative for delivering RA for emergency essential surgery for LL MSDs due to unavailability of anesthesiologists.

Meta-analysis and trial sequential analysis of randomized evidence comparing general anesthesia vs regional anesthesia for laparoscopic cholecystectomy

BACKGROUND

In an effort to further reduce the morbidity and mortality profile of laparoscopic cholecystectomy, the outcomes of such procedure under regional anesthesia (RA) have been evaluated. In the context of cholecystectomy, combining a minimally invasive surgical procedure with a minimally invasive anesthetic technique can potentially be associated with less postoperative pain and earlier ambulation.

AIM

To evaluate comparative outcomes of RA and general anesthesia (GA) in patients undergoing laparoscopic cholecystectomy.

METHODS

A comprehensive systematic review of randomized controlled trials with subsequent meta-analysis and trial sequential analysis of outcomes were conducted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards.

RESULTS

Thirteen randomized controlled trials enrolling 1111 patients were included. The study populations in the RA and GA groups were of comparable age (P = 0.41), gender (P = 0.98) and body mass index (P = 0.24). The conversion rate from RA to GA was 2.3%. RA was associated with significantly less postoperative pain at 4 h [mean difference (MD): - 2.22, P < 0.00001], 8 h (MD: -1.53, P = 0.0006), 12 h (MD: -2.08, P < 0.00001), and 24 h (MD: -0.90, P < 0.00001) compared to GA. Moreover, it was associated with significantly lower rate of nausea and vomiting [risk ratio (RR): 0.40, P < 0.0001]. However, RA significantly increased postoperative headaches (RR: 4.69, P = 0.03), and urinary retention (RR: 2.73, P = 0.03). The trial sequential analysis demonstrated that the meta-analysis was conclusive for most outcomes, with the exception of a risk of type 1 error for headache and urinary retention and a risk of type 2 error for total procedure time.

CONCLUSION

Our findings indicate that RA may be an attractive anesthetic modality for day-case laparoscopic cholecystectomy considering its associated lower postoperative pain and nausea and vomiting compared to GA. However, its associated risk of urinary retention and headache and lack of knowledge on its impact on procedure-related outcomes do not justify using RA as the first line anesthetic choice for laparoscopic cholecystectomy.

Hyperbaric prilocaine vs. hyperbaric bupivacaine for spinal anaesthesia in women undergoing elective caesarean section: a comparative randomised double-blind study

Hyperbaric bupivacaine spinal anaesthesia remains the gold standard for elective caesarean section, but the resultant clinical effects can be unpredictable. Hyperbaric prilocaine induces shorter motor block but has not previously been studied in the obstetric spinal anaesthesia setting. We aimed to compare duration of motor block after spinal anaesthesia with prilocaine or bupivacaine during elective caesarean section. In this prospective randomised, double-blind study, women with uncomplicated pregnancy undergoing elective caesarean section were eligible for inclusion. Exclusion criteria included: patients aged < 18 years; height < 155 cm or > 175 cm; a desire to breastfeed; or a contra-indication to spinal anaesthesia. Patients were randomly allocated to two groups: the prilocaine group underwent spinal anaesthesia with 60 mg intrathecal prilocaine; and the bupivacaine group received 12.5 mg intrathecal heavy bupivacaine. Both 2.5 µg sufentanil and 100 µg morphine were added to the local anaesthetic agent in both groups. The primary outcome was duration of motor block, which was assessed every 15 min after arriving in the post-anaesthetic care unit. Maternal haemodynamics, APGAR scores, pain scores, patient satisfaction and side-effects were recorded. Fifty patients were included, with 25 randomly allocated to each group. Median (IQR [range]) motor block duration was significantly shorter in the prilocaine group, 158 (125-188 [95-249]) vs. 220 (189-250 [89-302]) min, p < 0.001. Median length of stay in the post-anaesthetic care unit was significantly shorter in the prilocaine group, 135 (120-180 [120-230]) vs. 180 (150-195 [120-240]) min, p = 0.009. There was no difference between groups for: maternal intra-operative hypotension; APGAR score; umbilical cord blood pH; maternal postoperative pain; and patients' or obstetricians' satisfaction. We conclude that hyperbaric prilocaine induces a shorter and more reliable motor block than hyperbaric bupivacaine for women with uncomplicated pregnancy undergoing elective caesarean section.

Comparing the Effects of General Versus Regional Anesthesia on Postoperative Mortality in Total and Partial Hip Arthroplasty

Purpose

Total hip arthroplasty (THA) and partial hip arthroplasty (PHA) are performed in patients with hip joint dysfunction such as osteoarthritis or hip fractures and are associated with complications including mortality. There is a lack of evidence in the literature regarding whether the type of anesthesia (regional vs. general) is associated with increased postoperative mortality in patients undergoing hip arthroplasty. The present study compares early postoperative mortality between general or regional anesthesia administered to patients undergoing either THA or PHA.

Methods

A retrospective cohort was assembled using the 2015-2016 American College of Surgeons National Surgical Quality Improvement Program database. Adult patients undergoing hip arthroplasty under general or regional anesthesia were included. Patients were excluded if receiving any other type of anesthesia, as well as having an American Society of Anesthesiologists (ASA) physical status classification score ≥ 4, preoperative acute renal failure, severe congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or ascites. Adjusted odds of 30 days all-cause postoperative mortality according to the type of anesthesia were estimated by fitting multiple logistic regression models that included potential confounders and effect modifiers.

Results

A total of 60,897 patients were included in the study. Given that the interaction between the type of anesthesia and the type of arthroplasty was statistically significant, separated models were fitted for each type of arthroplasty. There was no evidence of an association between type of anesthesia and postoperative mortality in hip arthroplasty patients regardless of whether the arthroplasty was partial (odds ratio {OR} = 0.85; confidence interval {CI} 0.59-1.22) or total (OR = 0.68; CI 0.43-1.08).

Conclusion

The overall early postoperative mortality in adult hip arthroplasty patients is low in the absence of risk factors such as severe CHF, COPD, ascites, acute renal failure, and ASA score of 4 or higher. Our findings suggest there is no association between the type of anesthesia received (general vs. regional) and early postoperative mortality rates in patients undergoing hip arthroplasty, regardless of type (total vs. partial).

Outcomes of loco-regional anaesthesia in ureteroscopy for stone disease: a systematic review

PURPOSE OF REVIEW

Routine ureteroscopy (URS) for stone disease is performed under a general anaesthesia. However, controversy exists on the role of loco-regional anaesthesia and the outcomes associated with it. Here we review the challenges, outcomes and complications of loco-regional anaesthesia for URS. A Cochrane style review was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines to evaluate the outcomes of loco-reginal anaesthesia for URS in stone disease, including all English language articles from January 1980 and December 2019.

RECENT FINDINGS

Twenty-one studies (1843 procedures) with a mean age of 46 years and a male : female ratio of 1.2 : 1 underwent URS under loco-regional anaesthesia. The mean stone size was 9 mm (range:4-21 mm) and except five papers, all other papers included stones in the ureter of which the majority were in the distal ureter. The conversion to general anaesthesia was needed in 2.7% patients (range 1-21%) across studies, with a stone free rate of 48-100%. The complication rate varied from 1.4 to 36%. Although the intraoperative complications included ureteric injury (n = 21) or perforation (n = 4), the postoperative complications included fever (n = 37), urinary tract infection (n = 20), haematuria (n = 4), urosepsis (n = 4) and others (n = 7).

SUMMARY

The present systematic review shows that local anaesthetic URS is a potential alternative to general anaesthetic URS in carefully selected patients. Randomised controlled trials with subgroup analysis are required to further assess whether loco-regional anaesthesia URS is noninferior to general anaesthesia URS and might help determine if the former approach should become more widespread.

Spinal versus general anesthesia for outpatient joint arthroplasty: can the evidence keep up with the patients?

Total joint arthroplasty (TJA) is transitioning to be an outpatient rather than an inpatient procedure under national and institutional pressures to increase volumes while reducing hospital costs and length of stay. Innovative surgical and anesthesia techniques have allowed for earlier ambulation and physical therapy participation, maximizing the chance that an appropriately selected patient may be discharged within a day of surgery. The choice of anesthesia type is a modifiable factor that has a major impact on both surgical outcomes and discharge readiness. Recent large database studies have provided evidence for improved outcomes, including decreased mortality, with the use of spinal anesthesia. However, few randomized, controlled trials exist and database studies have limitations. Modern general anesthesia techniques, including total intravenous anesthesia and infusions targeted to anesthetic depth, may make some of these differences insignificant, especially when newer regional anesthesia and local infiltration analgesia techniques are incorporated into TJA enhanced recovery protocols. Multimodal analgesia for all TJA patients may also help minimize differences in pain. Perhaps even more important than anesthesia technique is the proper selection of patients likely to meet the necessary milestones for early discharge. In this article, we provide two contrasting viewpoints on the optimal primary anesthetic for outpatient TJA.