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Oweidat A, Kalagara H, Sondekoppam RV. Current concepts and targets for preventing the transition of acute to chronic postsurgical pain. Curr Opin Anaesthesiol 2024; 37:588-596. [PMID: 39087396 DOI: 10.1097/aco.0000000000001424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024]
Abstract
PURPOSE OF REVIEW It is estimated that approximately a third of patients undergoing certain surgeries may report some degree of persistent pain postoperatively. Chronic postsurgical pain (CPSP) reduces quality of life, is challenging to treat, and has significant socio-economic impact. RECENT FINDINGS From an epidemiological perspective, factors that predispose patients to the development of CPSP may be considered in relation to the patient, the procedure or, the care environment. Prevention or management of transition from acute to chronic pain often need a multidisciplinary approach beginning early in the preoperative period and continuing beyond surgical admission. The current concepts regarding the role of central and peripheral nervous systems in chronification of pain may provide targets for future therapies but, the current evidence seems to suggest that a multimodal analgesic approach of preventive analgesia along with a continued follow-up and treatment after hospital discharge may hold the key to identify and manage the transitioning of acute to chronic pain. SUMMARY A comprehensive multidisciplinary approach with prior identification of risk factors, minimizing the surgical insult and a culture of utilizing multimodal analgesia and continued surveillance beyond the period of hospitalization is an important step towards reducing the development of chronic pain. A transitional pain service model may accomplish many of these goals.
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Affiliation(s)
- Adeeb Oweidat
- Department of Anesthesia, University of Iowa Healthcare, Iowa City, Iowa
| | - Hari Kalagara
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Hong G, Zhong H, Illescas A, Reisinger L, Cozowicz C, Poeran J, Liu J, Memtsoudis SG. Trends in hip fracture surgery in the United States from 2016 to 2021: patient characteristics, clinical management, and outcomes. Br J Anaesth 2024:S0007-0912(24)00462-8. [PMID: 39242278 DOI: 10.1016/j.bja.2024.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 07/08/2024] [Accepted: 07/19/2024] [Indexed: 09/09/2024] Open
Abstract
INTRODUCTION Hip fractures are a serious health concern and a major contributor to healthcare resource utilisation. We aimed to investigate nationwide trends in the USA in patient characteristics and outcomes in patients after hip fracture repair surgery. METHODS From the Premier Healthcare dataset, we extracted patient encounters for surgical hip fracture repair from 2016 to 2021. Patient characteristics, comorbidities, complications, and anaesthetic and surgical details were analysed. Cochran-Armitage trend tests and simple linear regression were used to determine trends. RESULTS We included 347 086 hip fracture repair encounters. Notable trends included the following: median patient age declined from 82 yr [interquartile range: 73-88 yr] to 81 yr [interquartile range: 73-88 yr], (P-value=0.002), the proportion of female patients decreased from 68% to 66.2% (P-value=0.019); internal fixation was the most common intervention initially, but with a declining percentage from 49.9% to 43.8% (P-value <0.001); in general, patients carried a greater comorbidity burden, with the proportion with three or more Elixhauser comorbidities increasing from 56.4% to 58.6% (P-value=0.006); general anaesthesia remained the most common anaesthetic technique, from 68.90% to 56.80% without a significant trend; per 1000 inpatient days, the most common complication remained acute renal failure; despite a higher comorbidity burden, no complication showed a statistically significant upward trend, and many showed downward trends. CONCLUSIONS Over the 6-yr period from 2016 to 2021, a majority of hip fracture repairs continued to be performed under general anaesthesia but with that percentage declining over time. Notable trends included a lower percentage of female patients, an increase in femoral neck fractures, a higher comorbidity burden among patients, and a decrease in complications.
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Affiliation(s)
- Genewoo Hong
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anaesthesiology, Weill Cornell Medical College, New York, NY, USA.
| | - Haoyan Zhong
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Alex Illescas
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Lisa Reisinger
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Crispiana Cozowicz
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA
| | - Jiabin Liu
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anaesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Stavros G Memtsoudis
- Department of Anaesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, New York, NY, USA; Department of Anaesthesiology, Weill Cornell Medical College, New York, NY, USA
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Merk K, Arpey NC, Gonzalez AM, Valdez KE, Cohen-Rosenblum A, Edelstein AI, Suleiman LI. Racial and Ethnic Minorities Underrepresented in Pain Management Guidelines for Total Joint Arthroplasty: A Meta-analysis. Clin Orthop Relat Res 2024; 482:1698-1706. [PMID: 38497759 PMCID: PMC11343556 DOI: 10.1097/corr.0000000000003026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 02/07/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Total joint arthroplasty aims to improve quality of life and functional outcomes for all patients, primarily by reducing their pain. This goal requires clinical practice guidelines (CPGs) that equitably represent and enroll patients from all racial/ethnic groups. To our knowledge, there has been no formal evaluation of the racial/ethnic composition of the patient population in the studies that informed the leading CPGs on the topic of pain management after arthroplasty surgery. QUESTIONS/PURPOSES Using papers included in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines and comparing them with US National census data, we asked: (1) What is the representation of racial/ethnic groups in randomized controlled trials compared with their representation in the US national population? (2) Is there a relationship between the reporting of racial/ethnic groups and year of data collection/publication, location of study, funding source, or guideline section? METHODS Participant demographic data (study year published, study type, guideline section, year of data collection, study site, study funding, study size, gender, age, and race/ethnicity) were collected from articles cited by this guideline. Studies were included if they were full text, were primary research articles conducted primarily within the United States, and if they reported racial and ethnic characteristics of the participants. The exclusion criteria included duplicate articles, articles that included the same participant population (only the latest dated article was included), and the following article types: systematic reviews, nonsystematic reviews, terminology reports, professional guidelines, expert opinions, population-based studies, surgical trials, retrospective cohort observational studies, prospective cohort observational studies, cost-effectiveness studies, and meta-analyses. Eighty-two percent (223 of 271) of articles met inclusion criteria. Our original literature search yielded 27 papers reporting the race/ethnicity of participants, including 24 US-based studies and three studies conducted in other countries; only US-based studies were utilized as the focus of this study. We defined race/ethnicity reporting as the listing of participants' race or ethnicity in the body, tables, figures, or supplemental data of a study. National census information from 2000 to 2019 was then used to generate a representation quotient (RQ), which compared the representation of racial/ethnic groups within study populations to their respective demographic representation in the national population. An RQ value greater than 1 indicates an overrepresented group and an RQ value less than 1 indicates an underrepresented group, relative to the US population. Primary outcome measures of RQ value versus time of publication for each racial/ethnic group were evaluated with linear regression analysis, and race reporting and manuscript parameters were analyzed with chi-square analyses. RESULTS Two US-based studies reported race and ethnicity independently. Among the 24 US-based studies reporting race/ethnicity, the overall RQ was 0.70 for Black participants, 0.09 for Hispanic participants, 0.1 for American Indian/Alaska Natives, 0 for Native Hawaiian/Pacific Islanders, 0.08 for Asian participants, and 1.37 for White participants, meaning White participants were overrepresented by 37%, Black participants were underrepresented by 30%, Hispanic participants were underrepresented by 91%, Asian participants were underrepresented by 92%, American Indian/Alaska Natives were 90% underrepresented, and Native Hawaiian Pacific Islanders were virtually not represented compared with the US national population. On chi-square analysis, there were differences between race/ethnicity reporting among studies with academic, industry, and dual-supported funding sources (χ 2 = 7.449; p = 0.02). Differences were also found between race/ethnicity reporting among US-based and non-US-based studies (χ 2 = 36.506; p < 0.001), with 93% (25 of 27) of US-based studies reporting race as opposed to only 7% (2 of 27) of non-US-based studies. Finally, there was no relationship between race/ethnicity reporting and the year of data collection or guideline section referenced. CONCLUSION The 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines provide evidence-based recommendations that reflect the current standards in orthopaedic surgery, but the studies upon which they are based overwhelmingly underenroll and underreport racial/ethnic minorities relative to their proportions in the US population. As these factors impact analgesic administration, their continued neglect may perpetuate inequities in outcomes after TJA. CLINICAL RELEVANCE Our study demonstrates that all non-White racial/ethnic groups were underrepresented relative to their proportion of the US population in the 2021 Anesthesia and Analgesia in Total Joint Arthroplasty Clinical Practice Guidelines, underscoring a weakness in the orthopaedic surgery evidence base and questioning the overall external validity and generalizability of these combined CPGs. An effort should be made to equitably enroll and report outcomes for all racial/ethnic groups in any updated CPGs.
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Affiliation(s)
| | - Nicholas C. Arpey
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Alba M. Gonzalez
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Katia E. Valdez
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Anna Cohen-Rosenblum
- Department of Orthopaedic Surgery, Louisiana State University, New Orleans, LA, USA
| | - Adam I. Edelstein
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
| | - Linda I. Suleiman
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL, USA
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Bonsel JM, Kodali H, Poeran J, Bonsel GJ. Socioeconomic, Patient, and Hospital Determinants for the Utilization of Peripheral Nerve Blocks in Total Joint Arthroplasty. Anesth Analg 2024:00000539-990000000-00873. [PMID: 39042570 DOI: 10.1213/ane.0000000000007107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND While peripheral nerve blocks (PNBs) are associated with various improved outcomes in patients undergoing total hip or knee arthroplasty (THA/TKA), disparities in PNB utilization have been reported. This study assessed the importance of socioeconomic, demographic, clinical, and hospital determinants in explaining PNB utilization using the population-attributable risk (PAR) framework. Subsequently, we examined the association between PNB use and 3 secondary outcomes: Centers for Medicare and Medicaid Services (CMS)-defined complications, 90-day all-cause readmissions, and length of stay >3 days. METHODS This retrospective cohort study included 52,926 THA and 94,795 TKA cases from the 5% 2012 to 2021 Medicare dataset. Mixed-effects logistic regression models measured the association between study variables and PNB utilization. Variables of interest were demographic (age, sex), clinical (outpatient setting, diagnosis, prior hospitalizations in the year before surgery, Deyo-Charlson index, obesity, (non)-opioid abuse, smoking), socioeconomic (neighborhood Social Deprivation Index, race and ethnicity) and hospital variables (beds, ownership, region, rurality, resident-to-bed ratio). The model was used for the calculation of variable-specific and variable category-specific PARs (presented in percentages), reflecting the proportion of variation in PNB use explained after eliminating variables (or groups of variables) of interest with all other factors held constant. Subsequently, regression models measured the association between PNB use and secondary outcomes. Associations are presented with odds ratios (ORs) and 95% confidence intervals (95% CIs). RESULTS Socioeconomic and demographic variables accounted for only a small proportion of variation in PNB use (up to 3% and 7%, respectively). Clinical (THA: 46%; TKA: 34%) and hospital variables (THA: 31%; TKA: 22%) were the primary drivers of variation. In THA, variation by clinical variables was driven by increased PNB use in the inpatient setting (OR, 1.28 [95% CI, 1.07-1.53]) and decreased use in patients with ≥2 prior hospitalizations (OR, 0.72 [95% CI, 0.57-0.90]). Moreover, nonosteoarthritis diagnoses associated with reduced PNB utilization in THA (OR, 0.64 [95% CI, 0.58-0.72]) and TKA (OR, 0.35 [95% CI, 0.34-0.37]).In TKA, PNB use was subsequently associated with fewer complications (OR, 0.82 [95% CI, 0.75-0.90]) and less prolonged length of stay (OR, 0.90 [95% CI, 0.86-0.95]); no association was found for readmissions (OR, 0.98 [95% CI, 0.93-1.03]). In THA, associations did not reach statistical significance. CONCLUSIONS Among THA and TKA patients on Medicare, large variations exist in the utilization of PNBs by clinical and hospital variables, while demographic and socioeconomic variables played a limited role. Given the consistent benefits of PNBs, particularly in TKA patients, more standardized provision may be warranted to mitigate the observed variation.
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Affiliation(s)
- Joshua M Bonsel
- From the Department of Orthopedics and Sports Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Hanish Kodali
- Department of Population Health and Policy, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - Jashvant Poeran
- Department of Population Health and Policy, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
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Flyger SSB, Sorenson S, Pingel L, Karlsen APH, Nørskov AK, Mathiesen O, Maagaard M. Primary outcomes and anticipated effect sizes in randomised clinical trials assessing adjuncts to peripheral nerve blocks: A scoping review. Acta Anaesthesiol Scand 2024. [PMID: 38978187 DOI: 10.1111/aas.14489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/29/2024] [Accepted: 06/18/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Prolonging effects of adjuncts to local anaesthetics in peripheral nerve blocks have been demonstrated in randomised clinical trials. The chosen primary outcome and anticipated effect size have major impact on the clinical relevance of results in these trials. This scoping review aims to provide an overview of frequently used outcomes and anticipated effect sizes in randomised trials on peripheral nerve block adjuncts. METHODS For our scoping review, we searched MEDLINE, Embase and CENTRAL for trials assessing effects of adjuncts for peripheral nerve blocks published in 10 major anaesthesia journals. We included randomised clinical trials assessing adjuncts for single-shot ultrasound-guided peripheral nerve blocks, regardless of the type of interventional adjunct and control group, local anaesthetic used and anatomical localization. Our primary outcome was the choice of primary outcomes and corresponding anticipated effect size used for sample size estimation. Secondary outcomes were assessor of primary outcomes, the reporting of sample size calculations and statistically significant and non-significant results related to the anticipated effect sizes. RESULTS Of 11,854 screened trials, we included 59. The most frequent primary outcome was duration of analgesia (35/59 trials, 59%) with absolute and relative median (interquartile range) anticipated effect sizes for adjunct versus placebo/no adjunct: 240 min (180-318) and 30% (25-40) and for adjunct versus active comparator: 210 min (180-308) and 17% (15-28). Adequate sample size calculations were reported in 78% of trials. Statistically significant results were reported for primary outcomes in 45/59 trials (76%), of which 22% did not reach the anticipated effect size. CONCLUSION The reported outcomes and associated anticipated effect sizes can be used in future trials on adjuncts for peripheral nerve blocks to increase methodological homogeneity.
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Affiliation(s)
- Sarah Sofie Bitsch Flyger
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Sandra Sorenson
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Lasse Pingel
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Anders Peder Højer Karlsen
- Department of Anaesthesia and Intensive Care Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Anders Kehlet Nørskov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hillerød, Denmark
| | - Ole Mathiesen
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Maagaard
- Centre for Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
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Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Anesthesiol Clin 2024; 42:329-344. [PMID: 38705680 DOI: 10.1016/j.anclin.2023.11.013] [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] [Indexed: 05/07/2024]
Abstract
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
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Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
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Wu CL. 2024 Gaston Labat Award Lecture-outcomes research in Regional Anesthesia and Acute Pain Medicine: past, present and future. Reg Anesth Pain Med 2024; 49:307-312. [PMID: 38395462 DOI: 10.1136/rapm-2024-105286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Affiliation(s)
- Christopher L Wu
- Department of Anesthesiology, Critical Care Medicine and Pain Management, Hospital for Special Surgery, New York, New York, USA
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York, USA
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Kessler P. [Old and New Regional Anesthesia Procedures Under Review - Abdomen to Toe]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:159-179. [PMID: 38513641 DOI: 10.1055/a-2065-7660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Ultrasound (US) technology has significantly expanded the spectrum of regional anesthesiological procedures in recent years. Abdominal wall blocks are becoming an increasingly integral part of a multimodal postoperative pain concept after abdominal surgery, gynecological or urological interventions. Thoracic epidural analgesia remains the gold standard for extensive surgery. The requirement for rapid postoperative mobilization and discharge after lower extremity surgery has led to the abandonment of neuroaxial or plexus blocks in favor of selective, peripheral blocks such as the PENG block or adductor canal block. The following article is intended to show the reader the change in the use of regional anesthesiological procedures for abdominal wall and lower extremity blocks using selected blockages.
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Merz-Herrala J, Leu N, Anderson E, Lambeck A, Jefferson J, Sobrero M, Mantuani D, Mudda G, Nagdev A. Safety and Pain Reduction in Emergency Practitioner Ultrasound-Guided Nerve Blocks: A One-Year Retrospective Study. Ann Emerg Med 2024; 83:14-21. [PMID: 37747384 DOI: 10.1016/j.annemergmed.2023.08.482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 08/16/2023] [Accepted: 08/18/2023] [Indexed: 09/26/2023]
Abstract
STUDY OBJECTIVE Emergency practitioners use ultrasound-guided nerve blocks to alleviate pain. This study represents the largest registry of single-injection ultrasound-guided nerve blocks performed in an emergency department (ED) to date. We wished to assess the safety and pain score reductions associated with ED-performed ultrasound-guided nerve blocks. The main outcomes of interest were ultrasound-guided nerve block complication rates and change in patient-reported pain (0 to 10 on the VAS) pre and post ultrasound-guided nerve blocks. Other variables of interest were ultrasound-guided nerve block types and indications during the study period. METHODS This is a retrospective analysis of 420 emergency practitioner-performed ultrasound-guided nerve blocks through chart review over 1 year in the Highland ED. Four emergency physician abstractors reviewed all templated ultrasound-guided nerve block notes and nursing records over the study period. Inter-rater reliability was assessed using 10 randomly selected charts with 100% agreement for 70 key variables (Kappa=1, P<.001). RESULTS Seventy-five unique emergency practitioners performed 420 ultrasound-guided nerve blocks. Ultrasound-guided nerve blocks were most often performed by emergency residents (61.9%), advanced practice practitioners (21.2%), ultrasound fellowship-trained faculty (8.3%), interns (3.6%), nonultrasound fellowship-trained faculty (3.3%), and not recorded (1.7%). One complication occurred during the study (arterial puncture recognized through syringe aspiration without further sequelae). Among the 261 ultrasound-guided nerve blocks with preblock and postblock pain scores, there was an improvement in postblock pain scores. The mean pain scores decreased from 7.4 to 2.8 after an ultrasound-guided nerve block (difference 4.6, 95% confidence interval 3.9 to 5.2). CONCLUSIONS This 1-year retrospective study supports that emergency practitioner-performed ultrasound-guided nerve blocks have a low complication rate and are associated with reduced pain.
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Affiliation(s)
- Jeffrey Merz-Herrala
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA.
| | - Nathaniel Leu
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Erik Anderson
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Alexandra Lambeck
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Jamal Jefferson
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Max Sobrero
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Daniel Mantuani
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
| | - Galaxy Mudda
- Department of Anesthesia, Highland Hospital-Alameda Health System, Oakland, CA
| | - Arun Nagdev
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA
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Bijkerk V, Visser J, Jacobs LMC, Keijzer C, Warlé MC. Deep versus moderate neuromuscular blockade during total hip arthroplasty to improve postoperative quality of recovery and immune function: protocol for a randomised controlled study. BMJ Open 2023; 13:e073537. [PMID: 37640469 PMCID: PMC10462972 DOI: 10.1136/bmjopen-2023-073537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION There is accumulating evidence that deep neuromuscular blockade (NMB) improves intraoperative surgical conditions during laparoscopic surgery. Studies investigating the effects of deep NMB in open surgery are scarce. In theory, by limiting surgical damage through deeper muscle relaxation, postoperative inflammation and concomitant immune suppression can be reduced. Therefore, this study will investigate the effects of deep NMB during total hip arthroplasty, which demands a relatively large exposure of the hip joint through and in between muscles. METHODS AND ANALYSIS This study is a monocentre blinded randomised controlled trial in 100 patients undergoing total hip arthroplasty under general anaesthesia. Patients will be randomised in a 1:1 fashion to an intervention group of intraoperative deep NMB (a post-tetanic count of 1-2) or a control group receiving moderate NMB (a train-of-four count of 1-2). NMB will be achieved by continuous or bolus administration of rocuronium, respectively. The primary endpoint is the quality of recovery at postoperative day 1 measured by the Quality of Recovery-40 Questionnaire, analysed by Analysis of Variance. The secondary endpoint is postoperative innate immune function, measured by ex vivo production capacity of tumour necrosis factor and interleukin-1β on endotoxin stimulation of whole blood. ETHICS AND DISSEMINATION Ethical approval for this study was granted by the Medical Ethics Committee 'METC Oost-Nederland' (reference number 2022-15754). Informed consent will be obtained prior to study participation. Study results will be published in an international peer-reviewed journal. TRIAL REGISTRATION NUMBERS ClinicalTrials.gov Registry (NCT05562999) and EudraCT Registry (2022-002451-19).
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Affiliation(s)
- Veerle Bijkerk
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
- Department of Anesthesiology, Radboudumc, Nijmegen, The Netherlands
| | - Jetze Visser
- Department of Orthopedics, Radboudumc, Nijmegen, The Netherlands
| | | | | | - Michiel C Warlé
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
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White RS, Andreae MH, Lui B, Ma X, Tangel VE, Turnbull ZA, Jiang SY, Nachamie AS, Pryor KO. Antiemetic Administration and Its Association with Race: A Retrospective Cohort Study. Anesthesiology 2023; 138:587-601. [PMID: 37158649 DOI: 10.1097/aln.0000000000004549] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
BACKGROUND Anesthesiologists' contribution to perioperative healthcare disparities remains unclear because patient and surgeon preferences can influence care choices. Postoperative nausea and vomiting is a patient- centered outcome measure and a main driver of unplanned admissions. Antiemetic administration is under the sole domain of anesthesiologists. In a U.S. sample, Medicaid insured versus commercially insured patients and those with lower versus higher median income had reduced antiemetic administration, but not all risk factors were controlled for. This study examined whether a patient's race is associated with perioperative antiemetic administration and hypothesized that Black versus White race is associated with reduced receipt of antiemetics. METHODS An analysis was performed of 2004 to 2018 Multicenter Perioperative Outcomes Group data. The primary outcome of interest was administration of either ondansetron or dexamethasone; secondary outcomes were administration of each drug individually or both drugs together. The confounder-adjusted analysis included relevant patient demographics (Apfel postoperative nausea and vomiting risk factors: sex, smoking history, postoperative nausea and vomiting or motion sickness history, and postoperative opioid use; as well as age) and included institutions as random effects. RESULTS The Multicenter Perioperative Outcomes Group data contained 5.1 million anesthetic cases from 39 institutions located in the United States and The Netherlands. Multivariable regression demonstrates that Black patients were less likely to receive antiemetic administration with either ondansetron or dexamethasone than White patients (290,208 of 496,456 [58.5%] vs. 2.24 million of 3.49 million [64.1%]; adjusted odds ratio, 0.82; 95% CI, 0.81 to 0.82; P < 0.001). Black as compared to White patients were less likely to receive any dexamethasone (140,642 of 496,456 [28.3%] vs. 1.29 million of 3.49 million [37.0%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.78; P < 0.001), any ondansetron (262,086 of 496,456 [52.8%] vs. 1.96 million of 3.49 million [56.1%]; adjusted odds ratio, 0.84; 95% CI, 0.84 to 0.85; P < 0.001), and dexamethasone and ondansetron together (112,520 of 496,456 [22.7%] vs. 1.0 million of 3.49 million [28.9%]; adjusted odds ratio, 0.78; 95% CI, 0.77 to 0.79; P < 0.001). CONCLUSIONS In a perioperative registry data set, Black versus White patient race was associated with less antiemetic administration, after controlling for all accepted postoperative nausea and vomiting risk factors. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Michael H Andreae
- Department of Anesthesiology, University of Utah, Salt Lake City, Utah
| | - Briana Lui
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Xiaoyue Ma
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Virginia E Tangel
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Zachary A Turnbull
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Silis Y Jiang
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Anna S Nachamie
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Kane O Pryor
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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12
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Beletsky A, Currie M, Shen J, Maan R, Desilva M, Winston N, Gabriel RA. Association of patient characteristics with the receipt of regional anesthesia. Reg Anesth Pain Med 2023; 48:217-223. [PMID: 36635043 DOI: 10.1136/rapm-2022-103916] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 01/02/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Regional anesthesia (RA) may improve patient-related outcomes, including decreased operative complications, shortened recovery times, and lower hospital readmission rates. More analyses are needed using a diverse set of databases to examine characteristics associated with the receipt of RA. METHODS A national hospital database was queried for patients 18 years or older who underwent total shoulder arthroplasty (TSA), total knee arthroplasty (TKA), anterior cruciate ligament reconstruction (ACLR), carpal tunnel release, ankle open reduction, and internal fixation and arteriovenous fistula creation between January 2016 and June 2021. Regional techniques included neuraxial anesthesia and various upper and lower extremity peripheral nerve blocks to create a binary variable of RA receipt. Univariate statistics were used to compare characteristics associated based on RA receipt and multivariable regression identified factors associated with RA receipt. RESULTS A total of 51 776 patients were included in the analysis, of which 2111 (4.1%) received RA. Factors associated with decreased odds of RA receipt included black race (vs white race; OR 0.73, 95% CI 0.62 to 0.86), other non-white race (vs white race; OR 0.71, 95% CI 0.61 to 0.86), American Society of Anesthesiologists (ASA) class (vs ASA 1; OR 0.85, 95% CI 0.79 to 0.93), and Medicaid insurance (vs private insurance; OR 0.65, 95% CI 0.51 to 0.82) (all p<0.05). When compared with TKA, ACLR (OR 0.67, 95% CI 0.53 to 0.84), ankle open reduction and internal fixation (OR 0.68, 95% CI 0.58 to 0.81), and carpal tunnel release (OR 0.68, 95% CI 0.59 to 0.78) demonstrated lower odds of RA receipt, whereas TSA (OR 1.31, 95% CI 1.08 to 1.58) demonstrated higher odds of RA receipt (all p<0.05). CONCLUSION RA use varies with respect to race, insurance status, and type of surgery.
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Affiliation(s)
- Alexander Beletsky
- Anesthesiology, Riverside Community Hospital, Riverside, California, USA
| | - Morgan Currie
- Anesthesiology, Riverside Community Hospital, Riverside, California, USA
| | - Jonathan Shen
- Anesthesiology, Riverside Community Hospital, Riverside, California, USA
| | - Ramneek Maan
- Anesthesiology, Riverside Community Hospital, Riverside, California, USA
| | - Mahesh Desilva
- Anesthesiology, Riverside Community Hospital, Riverside, California, USA
| | - Nutan Winston
- Anesthesiology, Riverside Community Hospital, Riverside, California, USA
| | - Rodney A Gabriel
- Anesthesiology, University of California San Diego, La Jolla, California, USA
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13
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Nelson G, Fotopoulou C, Taylor J, Glaser G, Bakkum-Gamez J, Meyer LA, Stone R, Mena G, Elias KM, Altman AD, Bisch SP, Ramirez PT, Dowdy SC. Enhanced recovery after surgery (ERAS®) society guidelines for gynecologic oncology: Addressing implementation challenges - 2023 update. Gynecol Oncol 2023; 173:58-67. [PMID: 37086524 DOI: 10.1016/j.ygyno.2023.04.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/11/2023] [Accepted: 04/13/2023] [Indexed: 04/24/2023]
Abstract
BACKGROUND Despite evidence supporting its use, many Enhanced Recovery After Surgery (ERAS) recommendations remain poorly adhered to and barriers to ERAS implementation persist. In this second updated ERAS® Society guideline, a consensus for optimal perioperative care in gynecologic oncology surgery is presented, with a specific emphasis on implementation challenges. METHODS Based on the gaps identified by clinician stakeholder groups, nine implementation challenge topics were prioritized for review. A database search of publications using Embase and PubMed was performed (2018-2023). Studies on each topic were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded by an international panel according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS implementation challenge topics are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendations for stakeholder derived ERAS implementation challenges in gynecologic oncology are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- G Nelson
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - C Fotopoulou
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - J Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - J Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - L A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Stone
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Mena
- Department of Anesthesiology, Critical Care and Pain Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - K M Elias
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology and Reproductive Biology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - A D Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - S P Bisch
- Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA; Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, TX, USA
| | - S C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, MN, USA
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Héroux J, Bessette PO, Belley-Côté E, Lamarche D, Échavé P, Loignon MJ, Patenaude N, Baillargeon JP, D'Aragon F. Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review. BMC Anesthesiol 2023; 23:91. [PMID: 36964490 PMCID: PMC10037794 DOI: 10.1186/s12871-023-02038-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/08/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND Peripheral nerve block is a common anesthetic technique used during orthopedic upper limb surgery. Injection of local anesthetics around the target nerve inhibits the action of voltage-dependent sodium channels, inhibiting neurotransmission of pain impulses and providing motor immobility. Compared to general anesthesia, it could improve functional recovery by inhibiting nociceptive impulses and inflammation, thus reducing postoperative pain and immobilization and improving postoperative rehabilitation. This systematic review evaluates the impact of peripheral nerve block versus general anesthesia on postoperative functional recovery following orthopedic upper limb surgery. METHODS We searched CENTRAL, MEDLINE, CINHAL, EMBASE, and Scopus trial databases from inception until September 2021 for studies comparing peripheral nerve block to general anesthesia. We collected data on functional recovery, range of motion, patient satisfaction, quality of life, and return to work. We pooled studies using a random-effects model and summarized the quality of evidence with the GRADE approach. RESULTS We assessed 373 citations and 19 full-text articles for eligibility, and included six studies. Six studies reported on functional recovery, but failed to detect a significant superiority of peripheral nerve block over general anesthesia (3 RCT studies, N = 160; SMD -0.15; CI at 95% -0.60-0.3; I2 = 45%; p = 0.07; low quality of evidence and 3 observational studies, N = 377; SMD -0.35; CI at 95% -0.71-0.01; I2 = 64%; p = 0.06; very low quality of evidence). CONCLUSIONS Current literature is limited and fails to identify the benefit of peripheral nerve block on functional recovery. More studies are needed to assess the impact on long-term recovery. Considering the potential impact on clinical practice and training, a prospective study on functional recovery is ongoing (NCT04541745). TRIAL REGISTRATION PROSPERO ID CRD42018116298. Registered on December 4, 2018.
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Affiliation(s)
- Jennifer Héroux
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada.
| | | | - Emilie Belley-Côté
- Divisions of Cardiology and Critical Care, Department of Medicine, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
| | - Daphnée Lamarche
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Pablo Échavé
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Marie-Josée Loignon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Nicolas Patenaude
- Department of Orthopedic Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - Jean-Patrice Baillargeon
- Division of Endocrinology, Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - Frédérick D'Aragon
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
- Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
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15
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Thijssen M, Timmerman L, Koning NJ, Rinia M, van Dijk JFM, Cheuk-Alam J, Olthof K, Rekker S, Steegers MAH, van Boekel RLM. Multimodal analgesia practices for knee and hip arthroplasties in the Netherlands. A prospective observational study from the PAIN OUT registry. PLoS One 2022; 17:e0279606. [PMID: 36548295 PMCID: PMC9778981 DOI: 10.1371/journal.pone.0279606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Different multimodal pain management strategies following total hip arthroplasty(THA) and total knee arthroplasty (TKA) surgery are used in clinical practice. The optimal pain management strategy, however, remains unclear. This study aims to evaluate the differences in perioperative multimodal pain management strategies for THA and TKA in the Netherlands, and studies the associations between patient- and therapy related factors and pain outcomes. METHODS Data from the Dutch hospitals in the PAIN OUT network were used in this study. Demographic data, pain management strategy including perioperative medication use and anesthetic techniques were recorded and used in a multivariable regression analysis to study the association with maximum pain intensity, the duration of severe pain, pain interference in bed and postoperative nausea. RESULTS In 343 hip arthroplasty patients and 301 knee arthroplasty patients in seven hospitals, respectively 28 and 35 different combinations of analgesic regimens were used. The number of different drugs prescribed was not related to postoperative pain intensity. Female sex, younger age and spinal anesthesia were associated with higher postoperative maximum pain scores (Numeric Rating Scale (NRS) > 5). Hip surgery and ketamine use were associated with lower postoperative pain scores. The use of non-steroidal anti-inflammatory drugs (NSAIDs) and gabapentinoids, higher age, higher body mass index (BMI) and male gender were associated with less postoperative nausea (NRS < 3). CONCLUSION In conclusion, our study demonstrated a large diversity of analgesic strategies following total joint arthroplasties in the Netherlands. Although no ideal strategy was identified, the use of NSAIDs, ketamine and dexamethasone were associated with less pain and less side effects.
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Affiliation(s)
- Marloes Thijssen
- Department of Anesthesiology and Pain medicine, Antonius Hospital, Nieuwegein, The Netherlands
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Leon Timmerman
- Department of Anesthesiology and Pain medicine, Antonius Hospital, Nieuwegein, The Netherlands
| | - Nick J. Koning
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Myra Rinia
- Department of Anesthesiology and Pain Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Jacqueline F. M. van Dijk
- Department of Anesthesiology and Pain medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Juanita Cheuk-Alam
- Department of Anesthesiology and Pain Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Kees Olthof
- Department of Anesthesiology and Pain Medicine, Isala Hospital, Zwolle, The Netherlands
| | - Sjaak Rekker
- Department of Anesthesiology and Pain Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Monique A. H. Steegers
- Department of Anesthesiology and Pain Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Regina L. M. van Boekel
- Department of Anesthesiology and Pain Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- * E-mail:
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16
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McConnell L, Bulman J. Liberal use of local anaesthetic and the risk of toxicity in elective arthroplasties at a tertiary teaching hospital. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022. [DOI: 10.1177/25160435221135307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background Local anaesthetic systemic toxicity (LAST) is a life-threatening potential complication that may follow the administration of local anaesthetic (LA) drugs, and is cumulative across the drug class. Local anaesthetics are commonly administered via different routes for elective orthopaedic procedures – both by anaesthetists and surgeons. We hypothesized that total doses of LA may be routinely encroaching upon toxicity. Methods All total hip or knee arthroplasties (THAs and TKAs) performed within a 3 month period at the John Hunter Hospital (tertiary referral centre and teaching hospital) were audited to assess total administration of LA. Demographics, surgical characteristics, use of general anaesthesia or sedation, and use of local anaesthetic via any route of administration was recorded. For each patient, a weight-based theoretical maximum safe dose was calculated and compared against the dose they received. Data is presented as mean ± SD, percentages. Statistical significance was determined at p < 0.05. Results 130 THAs and TKAs were identified within the audit period. 52 patients exceeded their drug-class theoretical maximum safe dose. 49 patients exceeded their weight-based maximum dose for a single LA agent, in all cases ropivacaine. Non-obese individuals receive significantly higher mean dose than obese individuals (119.4% [98.6–140.3] vs 78.82% [65.95–91.69], p = 0.001). No LAST events were identified. Conclusions Patients who received elective total hip or knee arthroplasties were exposed to concerningly high total doses of local anaesthetic, suggesting that greater awareness of the additive toxicity of drugs within this class is required.
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Affiliation(s)
- Luke McConnell
- Department of Anaesthesia, John Hunter Hospital and University of Newcastle, Newcastle, New South Wales, Australia
| | - James Bulman
- JMO Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Callaghan, New South Wales, Australia
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17
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Little KJ. CORR Insights®: What Is the Risk of Postoperative Neurologic Symptoms After Regional Anesthesia in Upper Extremity Surgery? A Systematic Review and Meta-analysis of Randomized Trials. Clin Orthop Relat Res 2022; 480:2390-2391. [PMID: 36205500 PMCID: PMC10538918 DOI: 10.1097/corr.0000000000002422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/06/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Kevin J Little
- Director, Pediatric Hand and Upper Extremity Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Professor, Orthopaedic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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18
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Azad TD, Alomari S, Khalifeh JM, Ahmed AK, Musharbash FN, Mo K, Lubelski D, Witham TF, Bydon A, Theodore N. Adoption of awake spine surgery - trends from a national registry over 14 years. Spine J 2022; 22:1601-1609. [PMID: 35525378 DOI: 10.1016/j.spinee.2022.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/30/2022] [Accepted: 04/26/2022] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Tej D Azad
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Safwan Alomari
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Jawad M Khalifeh
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Farah N Musharbash
- Department of Orthopedic Surgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Kevin Mo
- Department of Orthopedic Surgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins Hospital, 600 N. Wolfe St, Meyer 7-113, Baltimore, 21287, MD, USA.
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Gerner P, Cozowicz C, Memtsoudis SG. Outcomes After Orthopedic Trauma Surgery - What is the Role of the Anesthesia Choice? Anesthesiol Clin 2022; 40:433-444. [PMID: 36049872 DOI: 10.1016/j.anclin.2022.04.001] [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] [Indexed: 06/15/2023]
Abstract
The body of literature concerning the influence of anesthetic type on many perioperative outcomes has grown considerably in recent years. Most studies have suggested that particularly in orthopedic patients, regional anesthesia may be associated with improved perioperative outcomes. Orthopedic trauma presents itself as a field that might benefit from increased utilization of regional techniques with the goal to improve outcomes. This narrative review concludes that, indeed, regional anesthesia seems to provide benefits for morbidity, pain control, and improved return to function in hip fracture, rib fracture, and isolated extremity fracture patients.
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Affiliation(s)
- Philipp Gerner
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02143, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria
| | - Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Muellner Hauptstrasse 48, Salzburg 5020, Austria.
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20
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Mazzeffi MA, Keneally R, Teal C, Douglas R, Starks V, Chow J, Porter SB. Racial Disparities in the Use of Peripheral Nerve Blocks for Postoperative Analgesia After Total Mastectomy: A Retrospective Cohort Study. Anesth Analg 2022; 135:170-177. [PMID: 35522889 DOI: 10.1213/ane.0000000000006058] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Peripheral nerve blocks (PNBs) are used to provide postoperative analgesia after total mastectomy. PNBs improve patient satisfaction and decrease postoperative opioid use, nausea, and vomiting. Few studies have examined whether there is racial-ethnic disparity in the use of PNBs for patients having total mastectomy. We hypothesized that non-Hispanic Asian, non-Hispanic Black, non-Hispanic patients of other races, and Hispanic patients would be less likely to receive a PNB for postoperative analgesia compared to non-Hispanic White patients having total mastectomy. Secondarily, we hypothesized that PNBs would be associated with reduced odds of major complications after total mastectomy. METHODS We performed a retrospective cohort study using National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2019. Patients were included if they underwent total mastectomy under general anesthesia. Unadjusted rates of PNB use were compared between race-ethnicity groups. Multivariable logistic regression was performed to determine whether race-ethnicity group was independently associated with receipt of a PNB for postoperative analgesia. Secondarily, we calculated crude and risk-adjusted odds ratios for major complications in patients who received a PNB. RESULTS There were 64,103 patients who underwent total mastectomy and 4704 (7.3%) received a PNB for postoperative analgesia. Patients who received a PNB were younger, more commonly women, were less likely to have diabetes and hypertension, and had less disseminated cancer (all P < .05). In our regression analysis, the odds of receiving a PNB differed significantly by race-ethnicity group (P < .001). Non-Hispanic Asian and non-Hispanic Black patients had reduced odds of receiving a PNB compared to non-Hispanic White patients (odds ratio [OR], 0.41; 95% confidence interval [CI], 0.33-0.49 and OR, 0.37 [0.32-0.44]), respectively. Non-Hispanic patients of other races, including American Indian, Alaskan Native, and Pacific Islander, also had reduced odds of receiving a PNB (OR, 0.73 [95% CI, 0.64-0.84]) compared to non-Hispanic White patients, as did Hispanic patients (OR, 0.62 [0.56-0.69]). Patients who received a PNB did not have reduced odds of major complications after mastectomy (crude OR, 0.83 [0.65-1.08]; P = .17 and adjusted OR, 0.85 [0.65-1.10]; P = .21). CONCLUSIONS Significant disparity exists in the use of PNBs for postoperative analgesia in patients of different race-ethnicity who undergo total mastectomy in the United States. Continued efforts are needed to better understand the causes of disparity and to ensure equitable access to PNBs.
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Affiliation(s)
| | - Ryan Keneally
- From the Departments of Anesthesiology and Critical Care Medicine
| | - Christine Teal
- Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Rundell Douglas
- George Washington University Milken Institute School of Public Health, Washington, DC
| | - Vanessa Starks
- From the Departments of Anesthesiology and Critical Care Medicine
| | - Jonathan Chow
- From the Departments of Anesthesiology and Critical Care Medicine
| | - Steven B Porter
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
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21
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Shams D, Sachse K, Statzer N, Gupta RK. Regional Anesthesia Complications and Contraindications. Clin Sports Med 2022; 41:329-343. [PMID: 35300844 DOI: 10.1016/j.csm.2021.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Regional anesthesia has a strong role in minimizing post-operative pain, decreasing narcotic use and PONV, and, therefore, speeding discharge times. However, as with any procedure, regional anesthesia has both benefits and risks. It is important to identify the complications and contraindications related to regional anesthesia, which patient populations are at highest risk, and how to mitigate those risks to the greatest extent possible. Overall, significant complications secondary to regional anesthesia remain low. While a variety of different regional anesthesia techniques exist, complications tend to fall within 4 broad categories: block failure, bleeding/hematoma, neurological injury, and local anesthetic toxicity.
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Affiliation(s)
- Danial Shams
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Kaylyn Sachse
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Nicholas Statzer
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA
| | - Rajnish K Gupta
- Department of Anesthesiology, Vanderbilt University Medical Center, 1301 Medical Center Drive, 4648 TVC, Nashville, TN 37232, USA.
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22
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Wei C, Muthiah A, Gu A, Quan T, Nguyen KT, Fassihi SC, Chen AZ, Amdur RL, Nunley RM, Liu J, Sculco PK, Berger JS. Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty. J Knee Surg 2022; 35:345-354. [PMID: 32663884 DOI: 10.1055/s-0040-1713776] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post hoc analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication (p = 0.008), perioperative blood transfusion (p < 0.001), and extended length of stay (p < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion (p < 0.001) and extended length of stay (p = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.
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Affiliation(s)
- Chapman Wei
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Arun Muthiah
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Alex Gu
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York City, New York
| | - Theodore Quan
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Kenneth T Nguyen
- New York Institute of Technology College of Osteopathic Medicine, Glen Head, New York
| | - Safa C Fassihi
- Department of Orthopedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Aaron Z Chen
- Weill Cornell Medical College, New York City, New York
| | - Richard L Amdur
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Ryan M Nunley
- Department of Orthopedic Surgery, Washington University at St Louis School of Medicine, St. Louis, Missouri
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York City, New York
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York City, New York
| | - Jeffrey S Berger
- Department of Anesthesiology & Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
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23
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Kwater AP, Hernandez N, Artime C, de Haan JB. Interscalene Block for Analgesia in Orthopedic Treatment of Shoulder Trauma: Single-Dose Liposomal Bupivacaine versus Perineural Catheter. Local Reg Anesth 2021; 14:167-178. [PMID: 34908874 PMCID: PMC8665777 DOI: 10.2147/lra.s303455] [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: 03/13/2021] [Accepted: 10/29/2021] [Indexed: 11/28/2022] Open
Abstract
Background Interscalene brachial plexus block is frequently utilized to provide perioperative analgesia to patients undergoing shoulder surgery to optimize recovery, minimize opioid consumption, and decrease overall hospital length of stay. The use of an indwelling perineural interscalene catheter provides extended analgesia and is efficacious in managing severe postoperative pain following major shoulder surgery. Currently, the only alternative to perineural catheters for extended analgesia with interscalene block involves the perineural infiltration of liposomal bupivacaine. However, there is limited published data regarding the overall analgesic effectiveness of using interscalene liposomal bupivacaine in the setting of shoulder surgery. Methods We performed a retrospective review of 43 patients in the acute trauma setting who underwent major shoulder surgery and received extended analgesia via perioperative interscalene brachial plexus block with either an indwelling continuous catheter or single-dose liposomal bupivacaine to determine if comparable analgesia can be achieved. The primary outcomes of interest were postoperative pain scores and opioid consumption. Due to the ability to titrate and bolus local anesthetic infusions to a desired clinical effect, we hypothesized that opioid consumption and pain scores would be lower when using the continuous catheter technique. Results After statistical analysis, our results demonstrated no significant difference between the two techniques in regards to opioid consumption as well as numeric pain scores during the 48-hour postoperative period, but did note a higher rate of complications with patients who received perineural interscalene continuous catheters. Secondary outcomes showed an increase in time required to complete the regional block procedure with the use of indwelling catheters. Conclusion Interscalene brachial plexus block with liposomal bupivacaine may be a viable alternative to indwelling continuous catheters for providing extended analgesia in patients undergoing major shoulder surgery.
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Affiliation(s)
- Andrzej P Kwater
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Nadia Hernandez
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Carlos Artime
- Department of Anesthesiology, McGovern Medical School at UTHealth, Houston, TX, USA
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24
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Gurney JK, McLeod MA, Campbell D, Dennett E, Jackson S, Koea J, Lash N, Ongley D. Anaesthetic choice for hip or knee arthroplasty in New Zealand: Risk of postoperative death and variations in use. Anaesth Intensive Care 2021; 50:178-188. [PMID: 34871516 DOI: 10.1177/0310057x211050934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Anaesthetic choice for large joint surgery can impact postoperative outcomes, including mortality. The extent to which the impact of anaesthetic choice on postoperative mortality varies within patient populations and the extent to which anaesthetic choice is changing over time remain under-explored both internationally and in the diverse New Zealand context. In a national study of 199,211 hip and knee replacement procedures conducted between 2005 and 2017, we compared postoperative mortality among those receiving general, regional or general plus regional anaesthesia. Focusing on unilateral (n=86,467) and partial (n=13,889) hip replacements, we assessed whether some groups within the population are more likely to receive general, regional or general plus regional anaesthesia than others, and whether mortality risk varies depending on anaesthetic choice. We also examined temporal changes in anaesthetic choice over time. Those receiving regional alone or general plus regional for unilateral hip replacement appeared at increased risk of 30-day mortality compared to general anaesthesia alone, even after adjusting for differences in terms of age, ethnicity, deprivation, rurality, comorbidity, American Society of Anesthesiologists physical status score and admission type (e.g. general plus regional: adjusted hazard ratio (adj. HR)=1.94, 95% confidence intervals (CI) 1.32 to 2.84). By contrast, we observed lower 30-day mortality among those receiving regional anaesthesia alone compared to general alone for partial hip replacement (adj. HR=0.86, 95% CI 0.75 to 0.97). The latter observation contrasts with declining temporal trends in the use of regional anaesthesia alone for partial hip replacement procedures. However, we recognise that postoperative mortality is one perioperative factor that drives anaesthetic choice.
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Affiliation(s)
- Jason K Gurney
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Melissa A McLeod
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Douglas Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland District Health Board, Auckland, New Zealand
| | - Elizabeth Dennett
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Sarah Jackson
- Department of Surgery, Capital and Coast District Health Board, Wellington, New Zealand
| | - Jonathan Koea
- Department of Surgery, Waitematā District Health Board, Auckland, New Zealand
| | - Nicholas Lash
- Department of Surgery, Canterbury District Health Board, Christchurch, New Zealand
| | - Dick Ongley
- Department of Anaesthesia, Canterbury District Health Board, Christchurch, New Zealand
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25
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Persistent Postoperative Opioid Prescription Fulfillment and Peripheral Nerve Blocks for Ambulatory Shoulder Surgery: A Retrospective Cohort Study. Anesthesiology 2021; 135:829-841. [PMID: 34525173 DOI: 10.1097/aln.0000000000003962] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There is need to identify perioperative interventions that decrease chronic opioid use. The authors hypothesized that receipt of a peripheral nerve block would be associated with a lower incidence of persistent postoperative opioid prescription fulfillment. METHODS This was a retrospective population-based cohort study examining ambulatory shoulder surgery patients in Ontario, Canada. The main outcome measure was persistent postoperative opioid prescription fulfillment. In opioid-naive patients (no opioid prescription fulfillment in 90 days preoperatively), this was present if an individual fulfilled an opioid prescription of at least a 60-day supply during postoperative days 90 to 365. In opioid-exposed (less than 60 mg oral morphine equivalent dose per day within 90 days preoperatively) or opioid-tolerant (60 mg oral morphine equivalent dose per day or above within 90 days preoperatively) patients, this was classified as present if an individual experienced any increase in opioid prescription fulfillment from postoperative day 90 to 365 relative to their baseline use before surgery. The authors' exposure was the receipt of a peripheral nerve block. RESULTS The authors identified 48,523 people who underwent elective shoulder surgery from July 1, 2012, to December 31, 2017, at one of 118 Ontario hospitals. There were 8,229 (17%) patients who had persistent postoperative opioid prescription fulfillment. Of those who received a peripheral nerve block, 5,008 (16%) went on to persistent postoperative opioid prescription fulfillment compared to 3,221 (18%) patients who did not (adjusted odds ratio, 0.90; 95% CI, 0.83 to 0.97; P = 0.007). This statistically significant observation was not reproduced in a coarsened exact matching sensitivity analysis (adjusted odds ratio, 0.85; 95% CI, 0.71 to 1.02; P = 0.087) or several other subgroup and sensitivity analyses. CONCLUSIONS This retrospective analysis found no association between receipt of a peripheral nerve block and a lower incidence of persistent postoperative opioid prescription fulfillment in ambulatory shoulder surgery patients. EDITOR’S PERSPECTIVE
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26
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Mariano ER, Dickerson DM, Szokol JW, Harned M, Mueller JT, Philip BK, Baratta JL, Gulur P, Robles J, Schroeder KM, Wyatt KEK, Schwalb JM, Schwenk ES, Wardhan R, Kim TS, Higdon KK, Krishnan DG, Shilling AM, Schwartz G, Wiechmann L, Doan LV, Elkassabany NM, Yang SC, Muse IO, Eloy JD, Mehta V, Shah S, Johnson RL, Englesbe MJ, Kallen A, Mukkamala SB, Walton A, Buvanendran A. A multisociety organizational consensus process to define guiding principles for acute perioperative pain management. Reg Anesth Pain Med 2021; 47:118-127. [PMID: 34552003 DOI: 10.1136/rapm-2021-103083] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 09/09/2021] [Indexed: 12/22/2022]
Abstract
The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.
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Affiliation(s)
- Edward R Mariano
- Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA .,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - David M Dickerson
- Department of Anesthesiology, Critical Care and Pain Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Anesthesia & Critical Care, University of Chicago Pritzker School of Medicine, Chicago, Illinois, USA
| | - Joseph W Szokol
- Department of Anesthesiology, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Michael Harned
- Department of Anesthesiology, Division of Pain Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Jeffrey T Mueller
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Beverly K Philip
- American Society of Anesthesiologists, Schaumburg, Illinois, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jaime L Baratta
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Padma Gulur
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer Robles
- Department of Urology, Division of Endourology and Stone Disease, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Surgical Service, Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Kristopher M Schroeder
- Department of Anesthesiology, University of Wisconsin School of Medicine, Madison, Wisconsin, USA
| | - Karla E K Wyatt
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Houston, Texas, USA.,Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, USA
| | - Jason M Schwalb
- Department of Neurological Surgery, Henry Ford Medical Group, Detroit, Michigan, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Richa Wardhan
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Todd S Kim
- Department of Orthopedic Surgery, Palo Alto Medical Foundation, Burlingame, California, USA
| | - Kent K Higdon
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Deepak G Krishnan
- Department of Oral & Maxillofacial Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,Department of Oral & Maxillofacial Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ashley M Shilling
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Gary Schwartz
- AABP Integrative Pain Care, Brooklyn, New York, USA.,Department of Anesthesiology, Maimonides Medical Center, Brooklyn, New York, USA
| | - Lisa Wiechmann
- Department of Surgery, NewYork-Presbyterian/Columbia University Medical Center, New York, New York, USA
| | - Lisa V Doan
- Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University Grossman School of Medicine, New York, New York, USA
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen C Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Iyabo O Muse
- Department of Anesthesiology, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
| | - Jean D Eloy
- Department of Anesthesiology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Vikas Mehta
- Department of Otolaryngology-Head and Neck Surgery, Montefiore Medical Center, Bronx, New York, USA
| | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine School of Medicine, Orange, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanda Kallen
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Ashley Walton
- American Society of Anesthesiologists, Washington, District of Columbia, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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27
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Neal-Smith G, Hopley E, Gourbault L, Watts DT, Abrahams H, Wilson K, Athanassoglou V. General Versus Regional Anaesthesia for Lower Limb Arthroplasty and Associated Patient Satisfaction Levels: A Prospective Service Evaluation in the Oxford University Hospitals. Cureus 2021; 13:e17024. [PMID: 34522505 PMCID: PMC8425506 DOI: 10.7759/cureus.17024] [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] [Accepted: 08/07/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Gregory Neal-Smith
- Orthopaedics, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Erin Hopley
- Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Lysander Gourbault
- Orthopaedics, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Daniel T Watts
- Orthopaedics, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Harry Abrahams
- Orthopaedics, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
| | - Katy Wilson
- Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, GBR
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28
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Peripheral nerve block use in ankle arthroplasty and ankle arthrodesis: utilization patterns and impact on outcomes. J Anesth 2021; 35:879-888. [PMID: 34480661 DOI: 10.1007/s00540-021-02994-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/24/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Ankle arthrodesis and total ankle arthroplasty (TAA) are often associated with significant postoperative pain. While this may be mitigated by the use of peripheral nerve blocks (PNB), large-scale data are lacking. Using national data, we aimed to evaluate PNB utilization pattern and its impact on outcomes. METHODS This retrospective cohort study utilized data from the nationwide database (2006-2016) on TAA (n = 5,290) and ankle arthrodesis (n = 14,709) procedures. PNB use was defined from billing; outcomes included opioid utilization, length and cost of stay, discharge to a skilled nurse facility, and opioid-related complications. Mixed-effects models estimated the association between PNB use and outcomes, separate by procedure type and inpatient/outpatient setting. We report odds ratios and 95% confidence intervals (CI). RESULTS Overall, PNB was utilized in 8.7% of TAA and 9.9% of ankle arthrodesis procedures, with increased utilization from 2006 to 2016 of 2.6% to 11.3% and 5.2% to 12.0%, respectively. After adjustment for relevant covariates, PNB use was significantly associated with decreased total opioid utilization specifically in the inpatient setting in TAA ( - 16.9% CI - 23.9%; - 9.1%) and ankle arthrodesis procedures ( - 18.9% CI - 24.4; - 13.0%), this was particularly driven by a decrease in opioid utilization on the day of surgery. No clinically relevant effects were observed for other outcomes. CONCLUSION PNB utilization is associated with substantial reductions in opioid utilization, particularly in the inpatient setting. Our study is in support of a wider use of this analgesic technique, which may translate into more benefits in terms of clinical outcomes and resource utilization. LEVEL OF EVIDENCE III.
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29
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Go G, Hargett MJ, Lee BH, Wendel P, Brouillette M, Kim SJ, Baaklini L, Wetmore DS, Hong G, Goto R, Jivanelli B, Athanassoglou V, Argyra E, Barrington MJ, Borgeat A, De Andres J, El-Boghdadly K, Elkassabany NM, Gautier P, Gerner P, Gonzalez Della Valle A, Goytizolo E, Guo Z, Hogg R, Kehlet H, Kessler P, Kopp S, Lavand'homme P, Macfarlane A, MacLean C, Mantilla C, McIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Peng P, Pichler L, Poeran J, Poultsides L, Schwenk ES, Sites BD, Stundner O, Sun EC, Viscusi E, Votta-Velis EG, Wu CL, YaDeau J, Sharrock NE. Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature. Reg Anesth Pain Med 2021; 46:971-985. [PMID: 34433647 DOI: 10.1136/rapm-2021-102750] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA .,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Edward R Mariano
- Anesthesiology and Perioperative Care Service, VA Palo Alto Health Care System, Palo Alto, California, USA.,Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Rebecca L Johnson
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Sang Jo Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Douglas S Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Rie Goto
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Bridget Jivanelli
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Vassilis Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Eriphili Argyra
- Faculty of Medicine, Aretaieion University Hospital, Athens, Greece
| | - Michael John Barrington
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Alain Borgeat
- Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia, Critical Care and Multidisciplinary Pain Management Department, Valencia University General Hospital, Valencia, Spain.,Anesthesia Unit, Surgical Specialties Department, School of Medicine, University of Valencia, Valencia, Spain
| | | | - Nabil M Elkassabany
- Anesthesiology and Critical Care, University Of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Philippe Gautier
- Department of Anesthesiology and Resuscitation, Clinique Sainte-Anne Saint-Remi, Brussels, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Zhenggang Guo
- Department of Anesthesiology, Peking Universtiy Shougang Hospital, Beijing, China
| | - Rosemary Hogg
- Department of Anaesthesia, Belfast Health and Social Care Trust, Belfast, UK
| | - Henrik Kehlet
- Department of Clinical Medicine, Rigshosp, Copenhagen, Denmark
| | - Paul Kessler
- Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Hessen, Germany
| | - Sandra Kopp
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Alan Macfarlane
- School of Medicine, Dentistry & Nursing, Glasgow Royal Infirmary and Stobhill Ambulatory Hospital, Glasgow, UK
| | - Catherine MacLean
- Center for the Advancement of Value in Musculoskeletal Care, Hospital for Special Surgery, New York, New York, USA.,Center for the Advancement of Value in Musculoskeletal Care, Weill Cornell Medical College, New York, New York, USA
| | - Carlos Mantilla
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Dan McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA.,Department of Orthopedic Surgery, Weill Cornell Medical College, New York, New York, USA
| | - Joseph M Neal
- Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA.,Benaroya Research Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Michael Parks
- Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Javad Parvizi
- Orthopedic Surgery, Rothman Orthopaedic Institute, Philadelphia, Pennsylvania, USA
| | - Philip Peng
- Anesthesia, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria
| | - Jashvant Poeran
- Orthopaedics/Population Health Science & Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lazaros Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, New York, USA
| | - Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian D Sites
- Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
| | - Ottokar Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical Private University, Salzburg, Austria.,Department of Anesthesiology and Intensive Care, Medical University of Innsbruck, Innsbruck, Tyrol, Austria
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Eugene Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Effrossyni Gina Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, Illinois, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Jacques YaDeau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA.,Department of Anesthesiology, Critical Care and Pain Management, Weill Cornell Medical College, New York, New York, USA
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30
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Lam S, Qu H, Hannum M, Tan KS, Afonso A, Tokita HK, McCormick PJ. Trends in Peripheral Nerve Block Usage in Mastectomy and Lumpectomy: Analysis of a National Database From 2010 to 2018. Anesth Analg 2021; 133:32-40. [PMID: 33481402 DOI: 10.1213/ane.0000000000005368] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Compared to general anesthesia, regional anesthesia confers several benefits including improved pain control and decreased postoperative opioid consumption. While the benefits of peripheral nerve blocks (PNB) have been well studied, there are little epidemiological data on PNB usage in mastectomy and lumpectomy procedures. The primary objective of our study was to assess national trends of the annual proportion of PNB use in breast surgery from 2010 to 2018. We also identified factors associated with PNB use for breast surgery. METHODS We identified lumpectomy and mastectomy surgical cases with and without PNB between 2010 and 2018 using the Anesthesia Quality Institute National Anesthesia Clinical Outcomes Registry (AQI NACOR). We modeled the nonlinear association between year of procedure and PNB use with segmented mixed-effects logistic regression clustered on facility identifier. The association between PNB use and year of procedure, age, sex, American Society of Anesthesiologists physical status (ASA PS), facility type, facility region, weekday, and tissue expander use was also modeled using mixed-effects logistic regression. RESULTS Of the 189,854 surgical cases from 2010 to 2018 that met criteria, 86.2% were lumpectomy cases and 13.8% were mastectomy cases. The proportion of lumpectomy cases with PNB was <0.1% in 2010 and increased each subsequent year to 1.9% in 2018 (trend P < .0001). The proportion of mastectomy cases with PNB was 0.5% in 2010 and 13% in 2018 (trend P < .0001). The year 2014 was the breakpoint selected for segmented regression. Before 2014, the odds of PNB among the mastectomy cases was not significantly different from year to year. After 2014, the odds of PNB increased by 2.24-fold each year (95% confidence interval [CI], 2.00-2.49; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. Similar trends were seen in the lumpectomy cases, where after 2014, the odds of PNB increased by 2.03-fold (95% CI, 1.81-2.27; P < .001); interaction test for pre-2014 versus post-2014 was P < .001. In the mastectomy cohort, year of procedure ≥2014, female sex, facility region, and tissue expander use were associated with higher odds of PNB. For lumpectomy cases, year of procedure ≥2014 and facility region were associated with higher odds of PNB use. CONCLUSIONS We found increased annual utilization of PNB for mastectomy and lumpectomy since 2010, although absolute prevalence is low. PNB use was associated with year of procedure for both lumpectomy and mastectomy, particularly post-2014.
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Affiliation(s)
- Stephanie Lam
- From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Helena Qu
- From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Margaret Hannum
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kay See Tan
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anoushka Afonso
- From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Hanae K Tokita
- From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Patrick J McCormick
- From the Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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31
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Disparities in the provision of regional anesthesia and analgesia in total joint arthroplasty: The role of patient and hospital level factors. J Clin Anesth 2021; 75:110440. [PMID: 34225182 DOI: 10.1016/j.jclinane.2021.110440] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 11/24/2022]
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32
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James D, Evans FM, Rai E, Roy N. Delivering Essential Surgical Care for Lower-limb Musculoskeletal disorders in the Low-Resource Setting. World J Surg 2021; 45:2975-2981. [PMID: 34189619 PMCID: PMC8408055 DOI: 10.1007/s00268-021-06211-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Deeptiman James
- Pediatric Orthopedic Unit, Department of Orthopedic, Christian Medical College Vellore, 1106, Paul Brand Building, Ida Scudder Road, Vellore, 632004, India.,Christian Hospital Mungeli, Mungeli, Chhattisgarh, 495334, India
| | - Faye M Evans
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, US
| | - Ekta Rai
- Department of Anesthesia, Head of Pediatric and ObGyn Anesthesia unit, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nobhojit Roy
- WHO Collaborating Center for Research on Surgical Care Delivery in LMICs, BARC Hospital, HBNI University, Mumbai, India. .,Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.
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Reisener MJ, Hughes AP, Okano I, Zhu J, Lu S, Salzmann SN, Shue J, Sama AA, Cammisa FP, Girardi FP, Soffin EM. The association of transversus abdominis plane block with length of stay, pain and opioid consumption after anterior or lateral lumbar fusion: a retrospective study. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:3738-3745. [PMID: 33934219 DOI: 10.1007/s00586-021-06855-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/23/2021] [Accepted: 04/18/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Anterior (ALIF) and lateral (LLIF) lumbar interbody fusion is associated with significant postoperative pain, opioid consumption and length of stay. Transversus abdominis plane (TAP) blocks improve these outcomes in other surgical subtypes but have not been applied to spine surgery. A retrospective study of 250 patients was performed to describe associations between TAP block and outcomes after ALIF/LLIF. METHODS The electronic medical records of 129 patients who underwent ALIF or LLIF with TAP block were compared to 121 patients who did not. All patients were cared for under a standardized perioperative care pathway with comprehensive multimodal analgesia. Differences in patent demographics, surgical factors, length of stay (LOS), opioid consumption, opioid-related side effects and pain scores were compared in bivariable and multivariable regression analyses. RESULTS In bivariable analyses, TAP block was associated with a significantly shorter LOS, less postoperative nausea/vomiting and lower opioid consumption in the post-anesthesia care unit (PACU). In multivariable analyses, TAP block was associated with significantly shorter LOS (β - 12 h, 95% CI (- 22, - 2 h); p = 0.021). Preoperative opioid use was a strong predictive factor for higher opioid consumption in the PACU, opioid use in the first 24 h after surgery and longer LOS. We did not find significant differences in pain scores at any times between the groups. CONCLUSION TAP block may represent an effective addition to pain management and opioid-reducing strategies and improve outcomes after ALIF/LLIF. Prospective trials are warranted to further explore these associations.
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Affiliation(s)
- Marie-Jacqueline Reisener
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Alexander P Hughes
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ichiro Okano
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jiaqi Zhu
- Department of Epidemiology and Biostatistics, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Shuting Lu
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Stephan N Salzmann
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Jennifer Shue
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Andrew A Sama
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Frank P Cammisa
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Federico P Girardi
- Department of Orthopedic Surgery, Spine Service, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care & Pain Management, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA.
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Zelaya P. Perioperative Peripheral Nerve Block Safety Education: A Quality Improvement Project. J Perianesth Nurs 2021; 36:359-366. [PMID: 33867246 DOI: 10.1016/j.jopan.2020.08.017] [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: 06/13/2020] [Revised: 08/17/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of the quality improvement (QI) project was to improve patient safety by increasing the consistency of monitor application and oxygen administration during the placement of peripheral nerve blocks (PNBs), advance the knowledge of perianesthesia staff about PNB safety, and develop a PNB hospital policy. DESIGN QI project using the focus, analyze, develop, and execute model. METHODS The project had two parts, an educational component that was deployed in the three hospitals (hospital A, hospital B, hospital C) and an observation component that was conducted in only one of the hospitals (hospital A). Baseline observation of monitor and oxygen application was recorded at hospital A for 3 months. Assessment of perioperative personnel's baseline knowledge regarding PNB safety was attained using a knowledge assessment tool in the three hospitals. Learners in the three hospitals were given a pretest and post-test to measure the change in knowledge level after a PNB safety presentation was given. Monitor and oxygen application during nerve block placements were observed and recorded after the PNB safety presentation at hospital A. Statistical analysis was completed to determine if significant differences in knowledge levels in the three hospitals and monitor and oxygen application at hospital A existed after an educational intervention was delivered to the perioperative teams. FINDINGS Participants' knowledge level increased 13% overall with post-test scores greater than 90% after the educational intervention. Monitor application and administration of oxygen during PNB placement improved from 2% to 100% in a preliminary 3-week postintervention review. Systematic changes were implemented to facilitate adherence to best practice measures. CONCLUSIONS PNB safety presentations significantly improved staff's knowledge regarding PNB procedures and potential problems. A multidisciplinary team approach was used to facilitate changes to improve electrocardiogram, blood pressure, pulse oximetry, and oxygen use in this patient population. A proposed PNB policy was accepted as a protocol. Patients are safer with increased monitoring.
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Affiliation(s)
- Pauline Zelaya
- Department of Anesthesiology, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM.
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35
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Analysis of anaesthesia services to calculate national need and supply of anaesthetics in Switzerland during the COVID-19 pandemic. PLoS One 2021; 16:e0248997. [PMID: 33740018 PMCID: PMC7978279 DOI: 10.1371/journal.pone.0248997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/09/2021] [Indexed: 11/19/2022] Open
Abstract
Background In Switzerland, details of current anaesthesia practice are unknown. However, they are urgently needed to manage anaesthesia drug supply in times of drug shortages due to the pandemic. Methods We surveyed all Swiss anaesthesia institutions in April 2020 to determine their annual anaesthesia activity. Together with a detailed analysis on anaesthetic drug use of a large, representative Swiss anaesthesia index institution, calculations and projections for the annual need of anaesthetics in Switzerland were made. Only those drugs have been analysed that are either being used very frequently or that have been classified critical with regard to their supply by the pharmacy of the index institution or the Swiss Federal Office of Public Health. Results The response rate to our questionnaire was 98%. Out of the present 188 Swiss anaesthesia institutions, 185 responded. In Switzerland, the annual number of anaesthesias was 1’071’054 (12’445 per 100’000 inhabitants) with a mean anaesthesia time of 2.03 hours. Teaching hospitals (n = 54) performed more than half (n = 572’231) and non-teaching hospitals (n = 103) provided almost half of all anaesthesias (n = 412’531). Thereby, private hospitals conducted a total of 290’690 anaesthesias. Finally, office-based anaesthesia institutions with mainly outpatients (n = 31) administered 86’292 anaesthesias. Regarding type of anaesthesia provided, two thirds were general anaesthesias (42% total intravenous, 17% inhalation, 8% combined), 20% regional and 12% monitored anaesthesia care. Projecting for example the annual need for propofol in anaesthesia, Switzerland requires 48’573 L of propofol 1% which corresponds to 5’644 L propofol 1% per 100’000 inhabitants every year. Conclusions To actively manage anaesthesia drug supply in the context of the current pandemic, it is mandatory to have a detailed understanding of the number and types of anaesthesias provided. On this basis, the Swiss annual consumption of anaesthetics could be projected and the replenishment organized.
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Jaffe E, Patzkowski MS, Hodgson JA, Foerschler DL, Gonzalez SC, Giordano NA, Scott-Richardson MP, Highland KB. Practice Variation in Regional Anesthesia Utilization by Current and Former U.S. Military Anesthesiology Residents. Mil Med 2021; 186:e98-e103. [PMID: 33038251 DOI: 10.1093/milmed/usaa269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
Introduction
Per Joint Trauma System guidelines, military anesthesiologists are expected to be ready to lead an Acute Pain Service with regional anesthesia in combat casualty care. However, regional anesthesia practice volume has not been assessed in the military. The objective of this study was to assess regional anesthesia utilization among current residents and graduates of U.S. military anesthesiology residency programs.
Materials and Methods
All current and former active duty military anesthesiology program residents, trained at any of the four military anesthesiology residency programs between 2013 and 2019, were anonymously surveyed about their regional anesthesia practice. Bivariate statistics described the total single-injection and catheter block techniques utilized in the last month. Cluster analysis assessed for the presence of distinct practice groups within the sample. Follow-up analyses explored potential associations between cluster membership and other variables (e.g., residency training site, residency graduation year, overall confidence in performing regional anesthesia, etc.). This protocol received exemption determination separately from each site’s institutional review board.
Results
Current and former residents reported broad variation in regional anesthesia practice and clustered into four distinct practice groups. Less than half of respondents utilized a moderate to high number of different single-injection and catheter blocks.
Conclusions
These findings highlight the need for creative solutions to increase regional anesthesia training in military anesthesiology programs and continued ability to implement skills, such that all military anesthesiologists have adequate practice for deployed responsibilities.
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Affiliation(s)
- Edward Jaffe
- School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA
| | | | - John A Hodgson
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Derek L Foerschler
- Department of Anesthesia, Naval Medical Center Portsmouth, Portsmouth, VA 23708, USA
| | - Sara C Gonzalez
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA 92134, USA
| | - Nicholas A Giordano
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| | - Maya P Scott-Richardson
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
| | - Krista B Highland
- Defense and Veterans Center for Integrative Pain Management, Department of Anesthesiology, Uniformed Services University, Bethesda, MD 20814, USA
- Henry M. Jackson Foundation Inc., Rockville, MD 20852, USA
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Post-operative outcomes and anesthesia type in total hip arthroplasty in patients with obstructive sleep apnea: A retrospective analysis of the State Inpatient Databases. J Clin Anesth 2020; 69:110159. [PMID: 33348291 DOI: 10.1016/j.jclinane.2020.110159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 11/24/2020] [Accepted: 11/28/2020] [Indexed: 12/21/2022]
Abstract
STUDY OBJECTIVES To investigate postoperative outcomes following total hip arthroplasty (THA) in patients with obstructive sleep apnea (OSA). To evaluate trends in the use of regional anesthesia (RA) versus general anesthesia (GA) following the publication of practical guidelines. To compare postoperative outcomes according to anesthesia type. DESIGN Retrospective analysis. SETTING Operating room. PATIENTS 349,008 patients who underwent elective THA in Florida, New York, Maryland, and Kentucky between 2007 and 2014 were extracted from the State Inpatient Databases (SID), Healthcare Cost and Utilization Project, including 18,063 patients with OSA (5.2%). INTERVENTIONS No intervention. MEASUREMENTS The effect of OSA on postoperative outcomes was investigated using bivariate analysis and multivariable logistic regression models. Outcomes studied included in-hospital mortality, postoperative complications, length of stay (LOS), and post-discharge readmissions. In a population from New York only, (n = 105,838 with 5306 patients with OSA [5.0%]), we investigated the outcomes in the OSA population according to the anesthesia type. Analysis was performed overall and for each individual year. MAIN RESULTS The OSA prevalence increased from 1.7% in 2007 to 7.1% in 2014. In multivariable analysis, there was no effect of OSA on in-hospital mortality (aOR:0.57; 0.31-1.04). Postoperative complications, LOS, and readmission rates were all higher in patients with OSA. In patients with OSA receiving GA than those receiving RA, we found a higher rate of complications overall and pulmonary complications specifically in men and higher rate of 90-day readmission in women. Over the study period, the rate of GA use in patients with OSA increased. CONCLUSIONS The OSA prevalence in patients undergoing THA increased fourfold over the study period. OSA was associated with increased overall postoperative complications, LOS, and readmission, but not with in-hospital mortality. Despite the publication of guidelines favoring RA over GA, the use of GA increased over the study period.
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Roberts DJ, Nagpal SK, Kubelik D, Brandys T, Stelfox HT, Lalu MM, Forster AJ, McCartney CJ, McIsaac DI. Association between neuraxial anaesthesia or general anaesthesia for lower limb revascularisation surgery in adults and clinical outcomes: population based comparative effectiveness study. BMJ 2020; 371:m4104. [PMID: 33239330 PMCID: PMC7687020 DOI: 10.1136/bmj.m4104] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To examine the associations between neuraxial anaesthesia or general anaesthesia and clinical outcomes, length of hospital stay, and readmission in adults undergoing lower limb revascularisation surgery. DESIGN Comparative effectiveness study using linked, validated, population based databases. SETTING Ontario, Canada, 1 April 2002 to 31 March 2015. PARTICIPANTS 20 988 patients Ontario residents aged 18 years or older who underwent their first lower limb revascularisation surgery in hospitals performing 50 or more of these surgeries annually. MAIN OUTCOME MEASURES Primary outcome was 30 day all cause mortality. Secondary outcomes were in-hospital cardiopulmonary and renal complications, length of hospital stay, and 30 day readmissions. Multivariable, mixed effects regression models, adjusting for patient, procedural, and hospital characteristics, were used to estimate associations between anaesthetic technique and outcomes. Robustness of analyses were evaluated by conducting instrumental variable, propensity score matched, and survival sensitivity analyses. RESULTS Of 20 988 patients who underwent lower limb revascularisation surgery, 6453 (30.7%) received neuraxial anaesthesia and 14 535 (69.3%) received general anaesthesia. The percentage of neuraxial anaesthesia use ranged from 0.6% to 90.6% across included hospitals. Furthermore, use of neuraxial anaesthesia declined by 17% over the study period. Death within 30 days occurred in 204 (3.2%) patients who received neuraxial anaesthesia and 646 (4.4%) patients who received general anaesthesia. After multivariable, multilevel adjustment, use of neuraxial anaesthesia compared with use of general anaesthesia was associated with decreased 30 day mortality (absolute risk reduction 0.72%, 95% confidence interval 0.65% to 0.79%; odds ratio 0.68, 95% confidence interval 0.57 to 0.83; number needed to treat to prevent one death=139). A similar direction and magnitude of association was found in instrumental variable, propensity score matched, and survival analyses. Use of neuraxial anaesthesia compared with use of general anaesthesia was also associated with decreased in-hospital cardiopulmonary and renal complications (odds ratio 0.73, 0.63 to 0.85) and a reduced length of hospital stay (-0.5 days, -0.3 to-0.6 days). CONCLUSIONS Use of neuraxial anaesthesia compared with general anaesthesia for lower limb revascularisation surgery was associated with decreased 30 day mortality and hospital length of stay. These findings might have been related to reduced cardiopulmonary and renal complications after neuraxial anaesthesia and support the increased use of neuraxial anaesthesia in patients undergoing these surgeries until the results of a large, confirmatory randomised trial become available.
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Affiliation(s)
- Derek J Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Sudhir K Nagpal
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Dalibor Kubelik
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Timothy Brandys
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine and O'Brien Institute for Public Health University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
| | - Alan J Forster
- Department of Medicine, Ottawa Hospital, Ottawa, ON, Canada
| | - Colin Jl McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa and The Ottawa Hospital, 1053 Carling Avenue, Ottawa, ON, Canada, K1Y 4E9
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
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Chan JJ, Cirino CM, Vargas L, Poeran J, Zubizarreta N, Mazumdar M, Galatz LM, Cagle PJ. Peripheral nerve block use in inpatient and outpatient shoulder arthroplasty: a population-based study evaluating utilization and outcomes. Reg Anesth Pain Med 2020; 45:818-825. [DOI: 10.1136/rapm-2020-101522] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/05/2020] [Accepted: 06/12/2020] [Indexed: 12/17/2022]
Abstract
BackgroundPeripheral nerve block (PNB) is an effective pain management option after shoulder arthroplasty with increasing popularity over the past decade. Large-scale US data in shoulder arthroplasties are lacking, especially regarding impacts on opioid utilization. This population-based study aimed to evaluate PNB utilization patterns and their effect on outcomes after inpatient and outpatient shoulder arthroplasty.MethodsThis retrospective cohort study used data from the nationwide Premier Healthcare claims database (2006–2016). This study includes n=94 787 and n=3293 inpatient and outpatient (total, reverse and partial) shoulder arthroplasty procedures. Multivariable mixed-effects models estimated associations between PNB use and opioid utilization in oral morphine equivalents and cost of hospitalization/stay. For the inpatient group, additional outcome measures were length of stay (LOS), admission to a skilled nurse facility, 30-day readmission, combined complications and naloxone use (as a proxy for opioid-related complications). We report OR (or % change for continuous variables) and 95% CIs.ResultsOverall, PNB was used in 19.1% (n=18 144) and 20.8% (n=685) of inpatient and outpatient shoulder arthroplasties, respectively, with an increasing trend for inpatient procedures. PNB utilization was consistently associated with lower (up to −14.0%, 95% CI −15.4% to −12.5% decrease, with median 100 and 90 oral morphine equivalents for inpatient and outpatient procedures) opioid utilization on the day of surgery with more potent effects seen for inpatient shoulder arthroplasties. Other outcomes were minimally impacted.DiscussionIn this first national study on PNB use in shoulder arthroplasty, we found increasing PNB use among specifically, inpatient procedures, resulting in particularly reduced opioid use on the day of surgery. While our findings may support PNB use in shoulder arthroplasty, its current low utilization and trends towards more outpatient procedures necessitate continuous monitoring of more extensive benefits.
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Charbonneau H, Mrozek S, Pradere B, Cornu JN, Misrai V. How to resume elective surgery in light of COVID-19 post-pandemic propofol shortage: The common concern of anaesthesists and surgeons. Anaesth Crit Care Pain Med 2020; 39:593-594. [PMID: 32753363 PMCID: PMC7347312 DOI: 10.1016/j.accpm.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/07/2020] [Accepted: 07/07/2020] [Indexed: 10/31/2022]
Affiliation(s)
- Hélène Charbonneau
- Department of Anaesthesia and Critical care, Clinique Pasteur, 31300 Toulouse, France.
| | - Ségolène Mrozek
- Department of Anaesthesia and Critical care, University Hospital of Toulouse, Toulouse, France
| | - Benjamin Pradere
- Department of Urology, University Hospital of Tours, Tours, France
| | | | - Vincent Misrai
- Department of Urology, Clinique Pasteur, 31300 Toulouse, France
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Johnson RL, Frank RD, Habermann EB, Chamberlain AM, Abdel MP, Schroeder DR, Mantilla CB. Neuraxial anesthesia is associated with improved survival after total joint arthroplasty depending on frailty: a cohort study. Reg Anesth Pain Med 2020; 45:405-411. [DOI: 10.1136/rapm-2019-101250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/17/2020] [Accepted: 03/23/2020] [Indexed: 12/20/2022]
Abstract
BackgroundFrailty increases risk for complications after total joint arthroplasty (TJA). Whether this association is influenced by anesthetic administered is unknown. We hypothesized that use of neuraxial (spinal or epidural) anesthesia is associated with better outcomes compared with general anesthesia, and that the effect of anesthesia type on outcomes differs by frailty status.MethodsThis single-institution cohort study included all patients (≥50 years) from January 2005 through December 2016 undergoing unilateral, primary and revision TJA. Using multivariable Cox regression, we assessed relationships between anesthesia type, a preoperative frailty deficit index (FI) categorized as non-frail (FI <0.11), vulnerable (FI 0.11 to 0.20), and frail (FI >0.20), and complications (mortality, infection, wound complications/hematoma, reoperation, dislocation, and periprosthetic fracture) within 1 year after surgery. Interactions between anesthesia type and frailty were tested, and stratified models were presented when an interaction (p<0.1) was observed.ResultsAmong 18 458 patients undergoing TJA, more patients were classified as frail (21.5%) and vulnerable (36.2%) than non-frail (42.3%). Anesthesia type was not associated with complications after adjusting for age, joint, and revision type. However, in analyzes stratified by frailty, vulnerable patients under neuraxial block had less mortality (HR=0.49; 95% CI 0.27 to 0.89) and wound complications/hematoma (HR=0.71; 95% CI 0.55 to 0.90), whereas no difference in risk by anesthesia type was observed among patients found non-frail or frail.ConclusionsNeuraxial anesthesia use among vulnerable patients was associated with improved survival and less wound complications. Calculating preoperative frailty prior to TJA informs perioperative risk and enhances shared-decision making for selection of anesthesia type.
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Risk score for major complications after total hip arthroplasty: the beneficial effect of neuraxial anesthesia. A retrospective observational study. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Nerve blocks improve early pain after ambulatory shoulder surgery; impact on postdischarge outcomes is poorly described. Our objective was to measure the association between nerve blocks and health system outcomes after ambulatory shoulder surgery.
Methods
We conducted a population-based cohort study using linked administrative data from 118 hospitals in Ontario, Canada. Adults having elective ambulatory shoulder surgery (open or arthroscopic) from April 1, 2009, to December 31, 2016, were included. After validation of physician billing codes to identify nerve blocks, we used multilevel, multivariable regression to estimate the association of nerve blocks with a composite of unplanned admissions, emergency department visits, readmissions or death within 7 days of surgery (primary outcome) and healthcare costs (secondary outcome). Neurology consultations and nerve conduction studies were measured as safety indicators.
Results
We included 59,644 patients; blocks were placed in 31,073 (52.1%). Billing codes accurately identified blocks (positive likelihood ratio 16.83, negative likelihood ratio 0.03). The composite outcome was not significantly different in patients with a block compared with those without (2,808 [9.0%] vs. 3,424 [12.0%]; adjusted odds ratio 0.96; 95% CI 0.89 to 1.03; P = 0.243). Healthcare costs were greater with a block (adjusted ratio of means 1.06; 95% CI 1.02 to 1.10; absolute increase $325; 95% CI $316 to $333; P = 0.005). Prespecified sensitivity analyses supported these results. Safety indicators were not different between groups.
Conclusions
In ambulatory shoulder surgery, nerve blocks were not associated with a significant difference in adverse postoperative outcomes. Costs were statistically higher with a block, but this increase is not likely clinically relevant.
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Héroux J, Belley-Côté E, Echavé P, Loignon MJ, Bessette PO, Patenaude N, Baillargeon JP, D’Aragon F. Functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery: a systematic review protocol. Syst Rev 2019; 8:273. [PMID: 31711533 PMCID: PMC6844046 DOI: 10.1186/s13643-019-1204-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 10/16/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Peripheral nerve block is a single injection that inhibits the transmission of peripheral nerve impulses to the central nervous system. The inhibition of the nociceptive impulse may decrease the occurrence of muscle spasm following mobilization postoperatively. This mechanism may contribute to a better functional recovery following upper limb surgery. This systematic review will investigate the impact of peripheral nerve block on functional recovery after an upper limb surgery. METHODS We will search studies comparing peripheral nerve block to general anesthesia for upper limb surgery in the following databases: CENTRAL, MEDLINE (Ovid), CINAHL, EMBASE, and Scopus. In duplicate, independent reviewers will assess eligibility, evaluate risk of bias, and abstract data on type of peripheral nerve block and functional outcome. Where possible, we will pool results using a random effects model. For each outcome, we will assess the quality of evidence using GRADE methodology. DISCUSSION We aim to summarize the available evidence comparing functional recovery with peripheral nerve block versus general anesthesia for upper limb surgery. These data will inform the design of a trial on the topic. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018116298.
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Affiliation(s)
| | | | - Pablo Echavé
- Université de Sherbrooke, Sherbrooke, Québec Canada
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Schnabel A, Reichl SU, Weibel S, Zahn PK, Kranke P, Pogatzki‐Zahn E, Meyer‐Frießem CH. Adductor canal blocks for postoperative pain treatment in adults undergoing knee surgery. Cochrane Database Syst Rev 2019; 2019:CD012262. [PMID: 31684698 PMCID: PMC6814953 DOI: 10.1002/14651858.cd012262.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Peripheral regional anaesthesia techniques are well established for postoperative pain treatment following knee surgery. The adductor canal block (ACB) is a new technique, which can be applied as a single shot or by catheter for continuous regional analgesia. OBJECTIVES To compare the analgesic efficacy and adverse events of ACB versus other regional analgesic techniques or systemic analgesic treatment for adults undergoing knee surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase, five other databases, and one trial register on 19 September 2018; we checked references, searched citations, and contacted study authors to identify additional studies. SELECTION CRITERIA We included all randomized controlled trials (RCTs) comparing single or continuous ACB versus other regional analgesic techniques or systemic analgesic treatment. Inclusion was independent of the technique used (landmarks, peripheral nerve stimulator, or ultrasound) and the level of training of providers. DATA COLLECTION AND ANALYSIS We used Cochrane's standard methodological procedures. Our primary outcomes were pain intensity at rest and during movement; rate of accidental falls; and rates of opioid-related adverse events. We used GRADE to assess the quality of evidence for primary outcomes. MAIN RESULTS We included 25 RCTs (1688 participants) in this review (23 trials combined within meta-analyses). In 18 studies, participants underwent total knee arthroplasty (TKA), whereas seven trials investigated patients undergoing arthroscopic knee surgery. We identified 11 studies awaiting classification and 11 ongoing studies. We investigated the following comparisons. ACB versus sham treatment We included eight trials for this comparison. We found no significant differences in postoperative pain intensity at rest (2 hours: standardized mean difference (SMD) -0.56, 95% confidence interval (CI) -1.20 to 0.07, 4 trials, 208 participants, low-quality evidence; 24 hours: SMD -0.49, 95% CI -1.05 to 0.07, 6 trials, 272 participants, low-quality evidence) or during movement (2 hours: SMD -0.59, 95% CI -1.5 to 0.33; 3 trials, 160 participants, very low-quality evidence; 24 hours: SMD 0.03, 95% CI -0.26 to 0.32, 4 trials, 184 participants, low-quality evidence). Furthermore, they noted no evidence of a difference in postoperative nausea between groups (24 hours: risk ratio (RR) 1.91, 95% CI 0.48 to 7.58, 3 trials, 121 participants, low-quality evidence). One trial reported that no accidental falls occurred 24 hours postoperatively (low-quality evidence). ACB versus femoral nerve block We included 15 RCTs for this comparison. We found no evidence of a difference in postoperative pain intensity at rest (2 hours: SMD -0.74, 95% CI -1.76 to 0.28, 5 trials, 298 participants, low-quality evidence; 24 hours: SMD 0.04, 95% CI -0.09 to 0.18, 12 trials, 868 participants, high-quality evidence) or during movement (2 hours: SMD -0.47, 95% CI -1.86 to 0.93, 2 trials, 88 participants, very low-quality evidence; 24 hours: SMD 0.56, 95% CI -0.00 to 1.12, 9 trials, 576 participants, very low-quality evidence). They noted no evidence of a difference in postoperative nausea (24 hours: RR 1.22, 95% CI 0.42 to 3.54, 2 trials, 138 participants, low-quality evidence) and no evidence that the rate of accidental falls during postoperative care was significantly different between groups (24 hours: RR 0.20, 95% CI 0.04 to 1.15, 3 trials, 172 participants, low-quality evidence). AUTHORS' CONCLUSIONS We are currently uncertain whether patients treated with ACB suffer from lower pain intensity at rest and during movement, fewer opioid-related adverse events, and fewer accidental falls during postoperative care compared to patients receiving sham treatment. The same holds true for the comparison of ACB versus femoral nerve block focusing on postoperative pain intensity. The overall evidence level was mostly low or very low, so further research might change the conclusion. The 11 studies awaiting classification and the 11 ongoing studies, once assessed, may alter the conclusions of this review.
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Affiliation(s)
- Alexander Schnabel
- University Hospital MünsterDepartment of Anesthesiology, Intensive Care and Pain MedicineAlbert‐Schweitzer‐Campus 1, Gebäude AMünsterGermany48149
| | - Sylvia U Reichl
- Paracelsus Medical UniversityDepartment of Anesthesiology, Perioperative and Intensive Care MedicineSalzburgAustria
| | - Stephanie Weibel
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Peter K Zahn
- BG‐Universitätsklinikum Bergmannsheil gGmbHDepartment of Anaesthesiology, Intensive Care Medicine and Pain ManagementBochumGermany
| | - Peter Kranke
- University of WürzburgDepartment of Anaesthesia and Critical CareOberduerrbacher Str. 6WürzburgGermany
| | - Esther Pogatzki‐Zahn
- University Hospital MünsterDepartment of Anesthesiology, Intensive Care and Pain MedicineAlbert‐Schweitzer‐Campus 1, Gebäude AMünsterGermany48149
| | - Christine H Meyer‐Frießem
- BG‐Universitätsklinikum Bergmannsheil gGmbHDepartment of Anaesthesiology, Intensive Care Medicine and Pain ManagementBochumGermany
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Sprung J, Schulte PJ, Knopman DS, Mielke MM, Petersen RC, Weingarten TN, Martin DP, Hanson AC, Schroeder DR, Warner DO. Cognitive function after surgery with regional or general anesthesia: A population-based study. Alzheimers Dement 2019; 15:1243-1252. [PMID: 31495602 PMCID: PMC6943821 DOI: 10.1016/j.jalz.2019.06.4949] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 06/14/2019] [Accepted: 06/19/2019] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Our aim was to examine whether surgery with regional anesthesia (RA) is associated with accelerated long-term cognitive decline comparable with that previously reported after general anesthesia (GA). METHODS Longitudinal cognitive function was analyzed in a cohort of 1819 older adults. Models assessed the rate of change in global and domain-specific cognition over time in participants exposed to RA or GA. RESULTS When compared with those unexposed to anesthesia, the postoperative rate of change of the cognitive global z-score was greater in those exposed to both RA (difference in annual decline of -0.041, P = .011) and GA (-0.061, P < .001); these rates did not differ. In analysis of the domain-specific scores, an accelerated decline in memory was observed after GA (-0.065, P < .001) but not RA (-0.011, P = .565). CONCLUSIONS Older adults undergoing surgery with RA experience decline of global cognition similar to those receiving GA; however, memory was not affected.
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Affiliation(s)
- Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Phillip J Schulte
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | | | - Ronald C Petersen
- Department of Neurology, Mayo Clinic, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew C Hanson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Darrell R Schroeder
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
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Memtsoudis SG, Cozowicz C, Bekeris J, Bekere D, Liu J, Soffin EM, Mariano ER, Johnson RL, Hargett MJ, Lee BH, Wendel P, Brouillette M, Go G, Kim SJ, Baaklini L, Wetmore D, Hong G, Goto R, Jivanelli B, Argyra E, Barrington MJ, Borgeat A, De Andres J, Elkassabany NM, Gautier PE, Gerner P, Gonzalez Della Valle A, Goytizolo E, Kessler P, Kopp SL, Lavand'Homme P, MacLean CH, Mantilla CB, MacIsaac D, McLawhorn A, Neal JM, Parks M, Parvizi J, Pichler L, Poeran J, Poultsides LA, Sites BD, Stundner O, Sun EC, Viscusi ER, Votta-Velis EG, Wu CL, Ya Deau JT, Sharrock NE. Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis. Br J Anaesth 2019; 123:269-287. [PMID: 31351590 DOI: 10.1016/j.bja.2019.05.042] [Citation(s) in RCA: 161] [Impact Index Per Article: 32.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/02/2019] [Accepted: 05/20/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER PROSPERO CRD42018099935.
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MESH Headings
- Anesthesia, Epidural/adverse effects
- Anesthesia, Epidural/mortality
- Anesthesia, General/adverse effects
- Anesthesia, General/mortality
- Anesthesia, Spinal/adverse effects
- Anesthesia, Spinal/mortality
- Arthroplasty, Replacement, Hip/methods
- Arthroplasty, Replacement, Hip/mortality
- Arthroplasty, Replacement, Knee/methods
- Arthroplasty, Replacement, Knee/mortality
- Evidence-Based Medicine/methods
- Humans
- Postoperative Complications/mortality
- Randomized Controlled Trials as Topic
- Treatment Outcome
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.
| | - Crispiana Cozowicz
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Janis Bekeris
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA; Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Dace Bekere
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jiabin Liu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Edward R Mariano
- Department of Anesthesia, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Rebecca L Johnson
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary J Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Bradley H Lee
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Pamela Wendel
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Mark Brouillette
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - George Go
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Sang J Kim
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Lila Baaklini
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Douglas Wetmore
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Genewoo Hong
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Rie Goto
- Kim Barrett Memorial Library, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Bridget Jivanelli
- Kim Barrett Memorial Library, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Eriphyli Argyra
- Department of Anaesthesiology, Pain and Palliative Care, National and Kapodistrian University of Athens, Athens, Greece
| | - Michael J Barrington
- Department of Medicine & Radiology, The University of Melbourne, Victoria, Australia
| | - Alain Borgeat
- Department of Anesthesiology and Intensive Care Medicine, Universität Zürich, Zurich, Switzerland
| | - Jose De Andres
- Anesthesia Unit- Surgical Specialties Department, Valencia University Medical School, Spain; Anesthesia, Critical Care, and Pain Management Department, General University Hospital, Valencia, Spain
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Philippe E Gautier
- Department of Anesthesiology, Clinique Ste-Anne St-Remi, Anderlecht, Belgium
| | - Peter Gerner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Alejandro Gonzalez Della Valle
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Enrique Goytizolo
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Paul Kessler
- Department of Anesthesiology, Intensive Care and Pain Medicine, Orthopedic University Hospital, Frankfurt am Main, Germany
| | - Sandra L Kopp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Catherine H MacLean
- Value Management Office, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Carlos B Mantilla
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Daniel MacIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexander McLawhorn
- Department of Orthopedic Surgery, Hip and Knee Replacement, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | - Joseph M Neal
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA, USA
| | - Michael Parks
- Department of Orthopedic Surgery, Hip and Knee Replacement, Hospital for Special Surgery, Weill Cornell Medical College, New York, NY, USA
| | | | - Lukas Pichler
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Jashvant Poeran
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York, NY, USA
| | - Lazaros A Poultsides
- Department of Orthopaedic Surgery, New York Langone Orthopaedic Hospital, New York, NY, USA
| | - Brian D Sites
- Department of Anesthesiology, Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Otto Stundner
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Eric C Sun
- Department of Anesthesia, Stanford University School of Medicine, Stanford, CA, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Pain Center, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Effrossyni G Votta-Velis
- Department of Anesthesiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
| | - Christopher L Wu
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Jacques T Ya Deau
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
| | - Nigel E Sharrock
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery and Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA
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Updates on multimodal analgesia and regional anesthesia for total knee arthroplasty patients. Best Pract Res Clin Anaesthesiol 2019; 33:111-123. [DOI: 10.1016/j.bpa.2019.02.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/23/2019] [Accepted: 02/26/2019] [Indexed: 01/17/2023]
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Asche CV, Dagenais S, Kang A, Ren J, Maurer BT. Impact of treatment with liposomal bupivacaine on hospital costs, length of stay, and discharge status in patients undergoing total knee arthroplasty at high-use institutions. J Med Econ 2019; 22:85-94. [PMID: 30378454 DOI: 10.1080/13696998.2018.1543190] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Aims: Post-surgical pain experienced by patients undergoing total knee arthroplasty (TKA) can be severe. Enhanced recovery after surgery programs incorporating multimodal analgesic regimens have evolved in an attempt to improve patient care while lowering overall costs. This study examined clinical and economic outcomes in hospitals using liposomal bupivacaine (LB) for pain control following TKA.Methods: This retrospective observational study utilized hospital chargemaster data from the Premier Healthcare Database from January 2011 through April 2017 for the 10 hospitals with the highest number of primary TKA procedures using LB. Within these hospitals, patients undergoing TKA who received LB were propensity-score matched in a 1:1 ratio to a control group not receiving LB. Outcomes included hospital length of stay (LOS), discharge status, 30-day same-hospital readmissions, total hospitalization costs, and opioid consumption; only patients with Medicare or commercial insurance as the primary payer for TKA were considered.Results: The study population included 20,907 Medicare-insured patients (LB = 10,411; control =10,496) and 12,505 patients with commercial insurance (LB = 6,242; control = 6,263). Overall, LOS was 0.6 days shorter with LB (p < 0.0001), and patients who received LB were 1.6-times more likely to be discharged home (p < 0.0001). Total hospitalization costs for the TKA procedure were lower with LB for patients with both Medicare (-$616; P < 0.0001) and commercial insurance (-$775; p < 0.0001). Opioid consumption was lower with LB in both payer populations (p < 0.0001). No significant differences for 30-day readmissions were found.Limitations: Costs were estimated using Premier charge-to-cost ratios and limited to goods and services recorded in the chargemaster. Findings from these 10 hospitals may not be representative of other US hospitals.Conclusions: In a sub-set of 10 US hospitals with the highest use of LB for TKA, LB use was associated with shorter hospital LOS, increased home discharge, lower total hospitalization costs, and decreased opioid use after TKA.
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Affiliation(s)
- Carl V Asche
- Center for Outcomes Research, University of Illinois College of Medicine, Peoria, IL, USA
| | | | - Amiee Kang
- Pacira Pharmaceuticals, Inc., Parsippany, NJ, USA
| | - Jinma Ren
- Center for Outcomes Research, University of Illinois College of Medicine, Peoria, IL, USA
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Nilsson U, Jaensson M, Dahlberg K, Hugelius K. Postoperative Recovery After General and Regional Anesthesia in Patients Undergoing Day Surgery: A Mixed Methods Study. J Perianesth Nurs 2018; 34:517-528. [PMID: 30470465 DOI: 10.1016/j.jopan.2018.08.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/19/2018] [Accepted: 08/19/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE To investigate differences and describe experiences of postoperative recovery after day surgery between patients undergoing general anesthesia (GA) versus regional anesthesia (RA). DESIGN A mixed methods design. METHODS Day surgery patients (N = 401) were included. Postoperative recovery was assessed daily for 14 days using the Swedish Web Version of the Quality of Recovery questionnaire included in a mobile application. In addition, qualitative interviews were completed with 20 day surgery patients. Quantitative and qualitative data were first analyzed separately and then merged. FINDINGS There were significant differences in Swedish Web Version of the Quality of Recovery between GA and RA on days 1 to 13 (P < .05). These findings could not be confirmed in the qualitative findings, except for psychological issues as well as tiredness and fatigue. Unexpected issues contributed to a greater extent to the theme not feeling well. Pain in the surgical wound was overall the biggest problem. CONCLUSIONS There seems to be a poorer recovery after GA compared with RA. Tiredness or fatigue is present also after minor surgery in RA. Unexpected issues affect recovery negatively, and therefore should be addressed by health care.
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