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Coppens M, Steenhout A, De Baerdemaeker L. Adjuvants for balanced anesthesia in ambulatory surgery. Best Pract Res Clin Anaesthesiol 2023; 37:409-420. [PMID: 37938086 DOI: 10.1016/j.bpa.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/15/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023]
Abstract
Balanced anesthesia relies on the simultaneous administration of different drugs to attain an anesthetic state. The classic triad of anesthesia is a combination of a hypnotic, an analgesic, and a neuromuscular blocker. It is predominantly the analgesic pillar of this triad that became more and more supported by adjuvant therapy. The aim of this approach is to evolve into an opioid-sparing technique to cope with undesirable side effects of the opioids and is fueled by the opioid epidemic. The optimal strategy for balanced general anesthesia in ambulatory surgery must aim for a transition to a multimodal analgesic regimen dealing with acute postoperative pain and ideally reduce the most common adverse effects patients are faced with at home; sore throat, delayed awakening, memory disturbances, headache, nausea and vomiting, and negative behavioral changes. Over the years, this continuum of "multimodal general anesthesia" adopted many drugs with different modes of action. This review focuses on the most recent evidence on the different adjuvants that entered clinical practice and gives an overview of the different mechanisms of action, the potential as opioid-sparing or hypnotic-sparing drugs, and the applicability specifically in ambulatory surgery.
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Affiliation(s)
- Marc Coppens
- University Hospital Ghent, Belgium, Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, University Ghent, Belgium.
| | - Annelien Steenhout
- Department of Anesthesiology and Perioperative Medicine, University Hospital, Ghent, Belgium.
| | - Luc De Baerdemaeker
- University Hospital Ghent, Belgium, Faculty of Medicine and Health Sciences, Department of Basic and Applied Medical Sciences, University Ghent, Belgium.
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Azimaraghi O, Ahrens E, Wongtangman K, Witt AS, Rupp S, Suleiman A, Tartler TM, Wachtendorf LJ, Fassbender P, Choice C, Houle TT, Eikermann M, Schaefer MS. Association of sugammadex reversal of neuromuscular block and postoperative length of stay in the ambulatory care facility: a multicentre hospital registry study. Br J Anaesth 2023; 130:296-304. [PMID: 36535827 DOI: 10.1016/j.bja.2022.10.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 10/09/2022] [Accepted: 10/20/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Encapsulation of rocuronium or vecuronium with sugammadex can reverse neuromuscular block faster than neostigmine reversal. This pharmacodynamic profile might facilitate patient discharge after ambulatory surgery. METHODS We included patients who underwent ambulatory surgery with general anaesthesia and neuromuscular block between 2016 and 2021 from hospital registries at two large academic healthcare networks in the USA. The primary outcome was postoperative length of stay in the ambulatory care facility (PLOS-ACF). We examined post hoc whether the type of reversal affects postoperative nausea and vomiting and direct hospital costs. RESULTS Among the 29 316 patients included, 8945 (30.5%) received sugammadex and 20 371 (69.5%) received neostigmine for reversal. PLOS-ACF and costs were lower in patients who received sugammadex vs neostigmine (adjusted difference in PLOS-ACF: -9.5 min; 95% confidence interval [95% CI], -10.5 to -8.5 min; adjusted difference in direct hospital costs: -US$77; 95% CI, -$88 to -$66; respectively; P<0.001). The association was magnified in patients over age 65 yr, with ASA physical status >2 undergoing short procedures (<2 h) (adjusted difference in PLOS-ACF: -18.2 min; 95% CI, -23.8 to -12.4 min; adjusted difference in direct hospital costs: -$176; 95% CI, -$220 to -$128; P<0.001). Sugammadex use was associated with reduced postoperative nausea and vomiting (17.2% vs 19.6%, P<0.001), which mediated its effects on length of stay. CONCLUSIONS Reversal with sugammadex compared with neostigmine was associated with a small decrease in postoperative length of stay in the ambulatory care unit. The effect was magnified in older and high-risk patients, and can be explained by reduced postoperative nausea and vomiting. Sugammadex reversal in ambulatory surgery may also help reduce cost of care.
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Affiliation(s)
- Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Annika S Witt
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Samuel Rupp
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aiman Suleiman
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Tim M Tartler
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Luca J Wachtendorf
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie, Operative Intensivmedizin, Schmerz- und Palliativmedizin, Marien Hospital Herne, Universitätsklinikum der Ruhr-Universität Bochum, Herne, Germany
| | - Curtis Choice
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy T Houle
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA; Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany.
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Center for Anesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA; Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
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Anesthetic Management during Robotic-Assisted Minimal Invasive Thymectomy Using the Da Vinci System: A Single Center Experience. J Clin Med 2022; 11:jcm11154274. [PMID: 35893373 PMCID: PMC9332370 DOI: 10.3390/jcm11154274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/14/2022] [Accepted: 07/20/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020−01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient’s age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH2O versus 19.3 ± 3.9 cmH2O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusions: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures.
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Safranek CW, Feitzinger L, Joyner AKC, Woo N, Smith V, Souza ED, Vasilakis C, Anderson TA, Fehr J, Shin AY, Scheinker D, Wang E, Xie J. Visualizing Opioid-Use Variation in a Pediatric Perioperative Dashboard. Appl Clin Inform 2022; 13:370-379. [PMID: 35322398 PMCID: PMC8942721 DOI: 10.1055/s-0042-1744387] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Anesthesiologists integrate numerous variables to determine an opioid dose that manages patient nociception and pain while minimizing adverse effects. Clinical dashboards that enable physicians to compare themselves to their peers can reduce unnecessary variation in patient care and improve outcomes. However, due to the complexity of anesthetic dosing decisions, comparative visualizations of opioid-use patterns are complicated by case-mix differences between providers. OBJECTIVES This single-institution case study describes the development of a pediatric anesthesia dashboard and demonstrates how advanced computational techniques can facilitate nuanced normalization techniques, enabling meaningful comparisons of complex clinical data. METHODS We engaged perioperative-care stakeholders at a tertiary care pediatric hospital to determine patient and surgical variables relevant to anesthesia decision-making and to identify end-user requirements for an opioid-use visualization tool. Case data were extracted, aggregated, and standardized. We performed multivariable machine learning to identify and understand key variables. We integrated interview findings and computational algorithms into an interactive dashboard with normalized comparisons, followed by an iterative process of improvement and implementation. RESULTS The dashboard design process identified two mechanisms-interactive data filtration and machine-learning-based normalization-that enable rigorous monitoring of opioid utilization with meaningful case-mix adjustment. When deployed with real data encompassing 24,332 surgical cases, our dashboard identified both high and low opioid-use outliers with associated clinical outcomes data. CONCLUSION A tool that gives anesthesiologists timely data on their practice patterns while adjusting for case-mix differences empowers physicians to track changes and variation in opioid administration over time. Such a tool can successfully trigger conversation amongst stakeholders in support of continuous improvement efforts. Clinical analytics dashboards can enable physicians to better understand their practice and provide motivation to change behavior, ultimately addressing unnecessary variation in high impact medication use and minimizing adverse effects.
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Affiliation(s)
- Conrad W. Safranek
- Department of Biology: Computational Biology, Stanford University, Stanford, United States
| | - Lauren Feitzinger
- Department of Management Science and Engineering, Stanford University, Stanford, United States
| | | | - Nicole Woo
- Department of Management Science and Engineering, Stanford University, Stanford, United States
- Department of Computer Science, Stanford University, Stanford, United States
| | - Virgil Smith
- Department of Management Science and Engineering, Stanford University, Stanford, United States
| | - Elizabeth De Souza
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Christos Vasilakis
- Bath Centre for Healthcare Innovation and Improvement, School of Management, Centre for Healthcare Innovation and Improvement, University of Bath, Bath, United Kingdom
| | - Thomas Anthony Anderson
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - James Fehr
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Andrew Y. Shin
- Department of Pediatrics—Cardiology, Stanford University School of Medicine, Stanford, California, United States
| | - David Scheinker
- Department of Management Science and Engineering, Stanford University, Stanford, United States
| | - Ellen Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - James Xie
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, United States
- Address for correspondence James Xie, MD Department of Anesthesiology, Perioperative and Pain Medicine300 Pasteur Drive, Room H3580 MC 5640, Stanford, CA 94305United States
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Haddad A, Szalai C, van Brakel L, Elhmidi Y, Arends S, Rabis M, Pop A, Ruhparwar A, Brenner T, Shehada SE. Fast-track anesthesia in lateral mini-thoracotomy for transapical transcatheter valve implantation. J Thorac Dis 2021; 13:4853-4863. [PMID: 34527324 PMCID: PMC8411149 DOI: 10.21037/jtd-21-751] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/14/2021] [Indexed: 11/06/2022]
Abstract
Background Patients who undergo transapical transcatheter aortic/mitral valve implantation are at higher risk of morbidity and mortality than those undergoing transvascular procedures. In addition, these patients have prolonged intensive care and hospital courses. Fast-track anesthesia could reduce perioperative complications and admission stays in such patients. Methods This retrospective single-center study, evaluates six high-risk patients undergoing transapical valve implantation between 01/2020 till 01/2021. All patients received a paravertebral block (PVB) as part of a fast-track approach. The airway was secured with a Gastro-double-lumen laryngeal mask which includes one orifice was for ventilation and one for the transesophageal echocardiography probe. Anesthesia was maintained with a volatile anesthetic (Sevoflurane MAC 1%). Immediately post procedure, all patients were awakened and admitted to the intermediate/intensive-care unit. Results Three patients were females, mean age =71±6 years, patients’ risk profiles were high (mean Log. EuroSCORE-I 22% & STS-PROM 10%). No incidents of re-intubation, atelectasis/pneumonia, low output syndrome, stroke, dialysis, pacemaker implantation or operative mortality were reported. One patient (16.7%) underwent re-exploration for bleeding and developed a wound infection. Postoperative pain scores showed that no patient required additional analgesics after the initial eight hours post procedure. Mean postoperative intermediate/intensive-care stay was 13.8±3.2 hours and patients were mobilized early and discharged to the normal ward. Conclusions Fast-track anesthesia using paravertebral-blockade for transcatheter transapical valve replacement in high-risk patients is a possible anesthetic approach. An effective PVB, in addition to a double-lumen laryngeal mask, provide an alternative strategy to conventional general anesthesia. These promising results could encourage further consideration of this approach in similar cardiac surgery patients.
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Affiliation(s)
- Ali Haddad
- Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Cynthia Szalai
- Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Lena van Brakel
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Yacine Elhmidi
- Department of Cardiac Surgery, Ludwigshafen Heart Centre, Ludwigshafen, Germany
| | - Sven Arends
- Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Marco Rabis
- Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Anca Pop
- Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Thorsten Brenner
- Department of Anesthesiology and Intensive Care Medicine, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, University Duisburg-Essen, Duisburg, Germany
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Lovett-Carter D, Kendall MC, Park J, Ibrahim-Hamdan A, Crepet S, De Oliveira G. The effect of systemic lidocaine on post-operative opioid consumption in ambulatory surgical patients: a meta-analysis of randomized controlled trials. Perioper Med (Lond) 2021; 10:11. [PMID: 33845914 PMCID: PMC8042682 DOI: 10.1186/s13741-021-00181-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 03/10/2021] [Indexed: 11/22/2022] Open
Abstract
Background Ambulatory surgical procedures continue to grow in relevance to perioperative medicine. Clinical studies have examined the use of systemic lidocaine as a component of multimodal analgesia in various surgeries with mixed results. A quantitative review of the opioid-sparing effects of systemic lidocaine in ambulatory surgery has not been investigated. The primary objective of this study was to systematically review the effectiveness of systemic lidocaine on postoperative analgesic outcomes in patients undergoing ambulatory surgery. Methods We performed a quantitative systematic review of randomized controlled trials in electronic databases (Cochrane Library, Embase, PubMed, and Google Scholar) from their inception through February 2019. Included trials investigated the effects of intraoperative systemic lidocaine on postoperative analgesic outcomes, time to hospital discharge, and adverse events. Methodological quality was evaluated using Cochrane Collaboration’s tool and the level of evidence was assessed using GRADE criteria. Data was combined in a meta-analysis using random-effects models. Results Five trials evaluating 297 patients were included in the analysis. The pooled effect of systemic lidocaine on postoperative opioid consumption at post-anesthesia care unit revealed a significant effect, weighted mean difference (95% CI) of − 4.23 (− 7.3 to 1.2, P = 0.007), and, at 24 h, weighted mean difference (95% CI) of − 1.91 (− 3.80 to − 0.03, P = 0.04) mg intravenous morphine equivalents. Postoperative pain control during both time intervals, postoperative nausea and vomiting reported at post anesthesia care unit, and time to hospital discharge were not different between groups. The incidence rate of self-limiting adverse events of the included studies is 0.007 (2/297). Conclusion Our results suggest that intraoperative systemic lidocaine as treatment for postoperative pain has a moderate opioid-sparing effect in post anesthesia care unit with limited effect at 24 h after ambulatory surgery. Moreover, the opioid-sparing effect did not impact the analgesia or the presence of nausea and vomiting immediately or 24 h after surgery. Clinical trials with larger sample sizes are necessary to further confirm the short-term analgesic benefit of systemic lidocaine following ambulatory surgery. Trial registration PROSPERO (CRD42019142229) Supplementary Information The online version contains supplementary material available at 10.1186/s13741-021-00181-9.
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Affiliation(s)
- Danielle Lovett-Carter
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Mark C Kendall
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA.
| | - James Park
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Anas Ibrahim-Hamdan
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Susannah Crepet
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
| | - Gildasio De Oliveira
- Department of Anesthesiology, The Warren Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI, 02903, USA
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