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Soffin EM, Abdallah FW, Mariano ER. Unwarranted variation in perioperative pain management for pediatric anterior cruciate ligament reconstruction: a call to improve the quality of quality improvement. Reg Anesth Pain Med 2024:rapm-2024-105637. [PMID: 38925709 DOI: 10.1136/rapm-2024-105637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Ellen M Soffin
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York, USA
| | - Faraj W Abdallah
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Edward R Mariano
- Anesthesiology, Perioperative and Pain Medicine 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
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Al-Saidi I, Russell A, Dizdarevic A. The Acute Perioperative Pain Service: Impact, Organization, and Future Directions. Curr Pain Headache Rep 2023; 27:399-405. [PMID: 37354296 DOI: 10.1007/s11916-023-01133-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/26/2023]
Abstract
PURPOSE OF REVIEW The Acute Perioperative Pain Service has been established as a relatively new but important concept and service in clinical patient care. Many surgical institutions have dedicated inpatient acute pain services with variable compositions. This review aims to investigate the purpose, clinical and economic implications, and future direction of the Acute Perioperative Pain Service (APPS). RECENT FINDINGS There is growing evidence of the multiple benefits of a dedicated APPS, especially pertaining to patients at higher risk of poorly controlled postoperative pain. Healthcare providers furthermore realize the importance of the perioperative pain management continuity of care, consisting of preoperative pain evaluations and post-discharge follow-up in an outpatient pain management setting, in coordination with the primary teams. The Transitional Pain Service (TPS) has emerged as the next step in this evolution and has been successfully implemented at various medical centers. With the growing number of surgical procedures and the increasing complexity of the patient population, effective management of acute postoperative pain continues to be challenging, despite ongoing advances in clinical care, analgesic modalities, and research. The APPS is becoming the clinical standard of care for managing postoperative pain, and its role continues to expand worldwide.
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Affiliation(s)
- Ibrahim Al-Saidi
- Columbia University Irving Medical Center, New York, USA.
- NewYork-Presbyterian/Columbia Univ Med Ctr, 622 W 168th St, NY, PH5-133 10032, New York, USA.
| | - Alex Russell
- Columbia University Irving Medical Center, New York, USA
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Schubert AK, Wiesmann T, Dinges HC. Measures to prolong duration of sensory block after regional anaesthesia. Curr Opin Anaesthesiol 2023; 36:103-108. [PMID: 36326074 DOI: 10.1097/aco.0000000000001204] [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: 11/06/2022]
Abstract
PURPOSE OF REVIEW The duration of single-injection regional anaesthesia is limited due to the inherent pharmacological properties of local anaesthetics. The ideal duration of a regional anaesthesia block lasting for the first 24 h postoperatively can be stated, while a residual analgesic effect thereafter is desirable.The aim of this review is to present current options to prolong the duration of action of single-injection peripheral regional anaesthesia in the ambulatory setting. Secondly, this review outlines and discusses the latest evidence regarding the clinical use of adjuvants and sustained-release local anaesthetics. RECENT FINDINGS Extended-release formulations of local anaesthetics such as liposomal bupivacaine have been developed to prolong regional anaesthesia up to 96 h. Recent studies, however, show that the actual effects remain far behind expectations and that the efficacy is only marginally better than bupivacaine hydrochloride.Adjuvants to local anaesthetics have been studied extensively with heterogenous results. Dexamethasone and alpha-2 agonists range among the most effective measures to prolong single-injection nerve blocks.Continuous nerve blocks and catheter techniques may prolong regional anaesthesia very effectively, but are less cost-effective regarding block procedure, postoperative care and handling logistical issues especially in ambulatory surgery. SUMMARY In conclusion, adjuvants are the recommended measure to prolong regional anaesthesia where needed. With good evidence supporting it, dexamethasone is the most effective adjuvant, followed by dexmedetomidine. Both have few side effects and a favourable safety profile. However, a preferable duration of analgesia lasting for the first 24 h postoperatively is still not reliably achievable.
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Affiliation(s)
- Ann-Kristin Schubert
- University Hospital Marburg, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstraße, Marburg
| | - Thomas Wiesmann
- University Hospital Marburg, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstraße, Marburg
- Department of Anesthesiology and Intensive Care Medicine, Diakoneo Diak Klinikum Schwäbisch-Hall, Schwäbisch-Hall, Germany
| | - Hanns-Christian Dinges
- University Hospital Marburg, Department of Anesthesia and Intensive Care, University Hospital Marburg, Baldingerstraße, Marburg
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Testa EJ, Lemme NJ, Li LT, DeFroda S. Trends in operative duration of total shoulder arthroplasty from 2008 to 2018: a national database study. Shoulder Elbow 2022; 14:534-543. [PMID: 36199510 PMCID: PMC9527484 DOI: 10.1177/17585732211008900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 01/17/2023]
Abstract
Background As total shoulder arthroplasty has emerged as the fastest growing joint replacement performed, optimizing surgical efficiency and patient outcomes is essential. The goals of the current study were to identify trends and factors affecting the operative time of total shoulder arthroplasty over a 10-year period. Methods The National Surgical Quality Improvement Program database was analyzed to determine the operative time and 30-day complications of total shoulder arthroplasty from 2008 to 2018. Factors affecting total shoulder arthroplasty operative time were also assessed. Multivariable linear regression was used to analyze operative time over years studied while controlling for patient demographics and comorbidities. Results A total of 20,587 total shoulder arthroplasty cases from 2008 to 2018 were included. Mean operative time in 2008 was 139.0 min, while in 2018, mean operative time decreased to 105.6 min (P < .001). Male sex, outpatient surgery, increased body mass index, and low preoperative hematocrit were associated with longer operative times, while elevated international normalized ratio, resident involvement, and elective surgeries were associated with decreased operative duration. Discussion Operative time for total shoulder arthroplasty has decreased from 2008 to 2018. Patient factors and comorbidities are associated with operative time, and such factors are important to consider in operative planning to ensure appropriate patient and surgeon expectations.
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Affiliation(s)
- Edward J Testa
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Nicholas J Lemme
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Lambert T Li
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Steven DeFroda
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, RI, USA
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Stone A, Lirk P, Vlassakov K. Rebound Pain After Peripheral Nerve Blockade-Bad Timing or Rude Awakening? Anesthesiol Clin 2022; 40:445-454. [PMID: 36049873 DOI: 10.1016/j.anclin.2022.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Patients who have perioperatively benefited from regional anesthesia frequently report moderate to severe pain when the nerve block effects fade away. Over the past years, the term "rebound pain" has been introduced, suggesting a specific pathologic process. It is debated whether significant pain on block resolution reflects a separate and distinct pathologic mechanism potentially involving proinflammatory and neurotoxic effects of local anesthetics, or is simply caused by the recovery of sensory function at a timepoint when nociceptive stimuli are still intense, and moderate to severe pain should be anticipated. In that latter case, the phenomenon referred to as rebound pain could be considered a failure of pain management providers to devise an adequate analgesia plan. Whatever the ultimate designation, management of rebound pain should be proactive, by implementing multimodal analgesia, or tailoring the blockade to the expected trajectory of postoperative pain and managing patient expectations accordingly. Until we know more about the etiology and impact of this phenomenon, the authors suggest a more neutral designation such as "pain on block resolution."
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Affiliation(s)
- Alexander Stone
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
| | - Philipp Lirk
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | - Kamen Vlassakov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Loewenstein SN, Bamba R, Adkinson JM. Emergency Department Utilization After Administration of Peripheral Nerve Blocks for Upper Extremity Surgery. Hand (N Y) 2022; 17:624-629. [PMID: 35815366 PMCID: PMC9274871 DOI: 10.1177/1558944720963867] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND The purpose of this study was to determine the impact of upper extremity peripheral nerve blocks on emergency department (ED) utilization after hand and upper extremity surgery. METHODS We reviewed all outpatient upper extremity surgeries performed in a single Midwestern state between January 2009 and June 2019 using the Indiana Network for Patient Care. These encounters were used to develop a database of patient demographics, comorbidities, concurrent procedures, and postoperative ED visit utilization data. We performed univariate, bivariate, and multivariate logistic regression analyses. RESULTS Among 108 451 outpatient surgical patients, 9079 (8.4%) received blocks. Within 1 week of surgery, a greater proportion of patients who received peripheral nerve blocks (1.4%) presented to the ED than patients who did not (0.9%) (P < .001). The greatest risk was in the first 2 postoperative days (relative risk, 1.78; P < .001). Pain was the principal reason for ED utilization in the block cohort (53.6%) compared with those who did not undergo a block (35.1%) (P < .001). When controlling for comorbidities and demographics, only peripheral nerve blocks (adjusted odds ratio [OR], 1.71; P = 0.007) and preprocedural opioid use (adjusted OR, 1.43; P = .020) conferred an independently increased risk of ED utilization within the first 2 postoperative days. CONCLUSIONS Peripheral nerve blocks used for upper extremity surgery are associated with a higher risk of unplanned ED utilization, most likely related to rebound pain. Through proper patient education and pain management, we can minimize this unnecessary resource utilization.
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Affiliation(s)
| | - Ravinder Bamba
- Indiana University School of Medicine, Indianapolis, USA
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7
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Mariano ER, McCartney CJL. Regional anesthesia and enhanced recovery after colorectal surgery: are we asking the right questions? Reg Anesth Pain Med 2022; 47:279-281. [DOI: 10.1136/rapm-2022-103549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/07/2022] [Indexed: 01/22/2023]
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8
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May KA, Craven JM, Wright C, Tran B. Regional anesthesia and the acute pain service: compliance and controversies. Curr Opin Anaesthesiol 2022; 35:224-229. [PMID: 35125395 DOI: 10.1097/aco.0000000000001118] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aims of this article are three-fold: first, to describe the necessary elements that result in accurate and compliant billing practice; second, to discuss billing in the context of new blocks and liposomal bupivacaine; and third, to gain a better understanding of compliance law. RECENT FINDINGS Regional anesthesia techniques provide an appealing alternative to opioid medication for pain management. However, these techniques also increase the cost of care. As new peripheral and fascial plane blocks emerge, proper coding has become more complex. SUMMARY Familiarity with documentation, billing, and compliance requirements can help maintain proper reimbursement rates, as well as limit potential downstream consequences. Most importantly this can help increase the viability and success of an acute pain service.
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Affiliation(s)
- Keith A May
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
| | - Jack M Craven
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
| | - Crystal Wright
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryant Tran
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
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9
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Zhong H, Thor P, Illescas A, Cozowicz C, Della Valle AG, Liu J, Memtsoudis SG, Poeran J. An Overview of Commonly Used Data Sources in Observational Research in Anesthesia. Anesth Analg 2022; 134:548-558. [PMID: 35180172 DOI: 10.1213/ane.0000000000005880] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anesthesia research using existing databases has drastically expanded over the last decade. The most commonly used data sources in multi-institutional observational research are administrative databases and clinical registries. These databases are powerful tools to address research questions that are difficult to answer with smaller samples or single-institution information. Given that observational database research has established itself as valuable field in anesthesiology, we systematically reviewed publications in 3 high-impact North American anesthesia journals in the past 5 years with the goal to characterize its scope. We identified a wide range of data sources used for anesthesia-related research. Research topics ranged widely spanning questions regarding optimal anesthesia type and analgesic protocols to outcomes and cost of care both on a national and a local level. Researchers should choose their data sources based on various factors such as the population encompassed by the database, ability of the data to adequately address the research question, budget, acceptable limitations, available data analytics resources, and pipeline of follow-up studies.
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Affiliation(s)
- Haoyan Zhong
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Pa Thor
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Alex Illescas
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Crispiana Cozowicz
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | | | - Jiabin Liu
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York.,Departments of Anesthesiology
| | - Stavros G Memtsoudis
- From the Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York.,Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria.,Departments of Anesthesiology.,Health Policy and Research, Weill Cornell Medical College, New York, New York
| | - Jashvant Poeran
- Departments of Population Health Science and Policy.,Department of Orthopedics, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York, New York
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10
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Sun EC, Rishel CA, Jena AB. Association Between Changes in Postoperative Opioid Utilization and Long-Term Health Care Spending Among Surgical Patients With Chronic Opioid Utilization. Anesth Analg 2022; 134:515-523. [PMID: 35180168 PMCID: PMC8867889 DOI: 10.1213/ane.0000000000005865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND There is growing interest in identifying and developing interventions aimed at reducing the risk of increased, long-term opioid use among surgical patients. While understanding how these interventions impact health care spending has important policy implications and may facilitate the widespread adoption of these interventions, the extent to which they may impact health care spending among surgical patients who utilize opioids chronically is unknown. METHODS This study was a retrospective analysis of administrative health care claims data for privately insured patients. We identified 53,847 patients undergoing 1 of 10 procedures between January 1, 2004, and September 30, 2018 (total knee arthroplasty, total hip arthroplasty, laparoscopic cholecystectomy, open cholecystectomy, laparoscopic appendectomy, open appendectomy, cesarean delivery, functional endoscopic sinus surgery, transurethral resection of the prostate, or simple mastectomy) who had chronic opioid utilization (≥10 prescriptions or ≥120-day supply in the year before surgery). Patients were classified into 3 groups based on differences in opioid utilization, measured in average daily oral morphine milligram equivalents (MMEs), between the first postoperative year and the year before surgery: "stable" (<20% change), "increasing" (≥20% increase), or "decreasing" (≥20% decrease). We then examined the association between these 3 groups and health care spending during the first postoperative year, using a multivariable regression to adjust for observable confounders, such as patient demographics, medical comorbidities, and preoperative health care utilization. RESULTS The average age of the sample was 62.0 (standard deviation [SD] 13.1) years, and there were 35,715 (66.3%) women. Based on the change in average daily MME between the first postoperative year and the year before surgery, 16,961 (31.5%) patients were classified as "stable," 15,463 (28.7%) were classified as "increasing," and 21,423 (39.8%) patients were classified as "decreasing." After adjusting for potential confounders, "increasing" patients had higher health care spending ($37,437) than "stable" patients ($31,061), a difference that was statistically significant ($6377; 95% confidence interval [CI], $5669-$7084; P < .001), while "decreasing" patients had lower health care spending ($29,990), a difference (-$1070) that was also statistically significant (95% CI, -$1679 to -$462; P = .001). These results were generally consistent across an array of subgroup and sensitivity analyses. CONCLUSIONS Among patients with chronic opioid utilization before surgery, subsequent increases in opioid utilization during the first postoperative year were associated with increased health care spending during that timeframe, while subsequent decreases in opioid utilization were associated with decreased health care spending.
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Affiliation(s)
- Eric C. Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Chris A. Rishel
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Anupam B. Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA; and Department of Medicine, Massachusetts General Hospital, Boston, MA; and National Bureau of Economic Research, Cambridge, MA
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11
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McGinn R, Talarico R, Hamiltoon GM, Ramlogan R, Wijeysundra DN, McCartney CJL, McIsaac DI. Hospital-, anaesthetist-, and patient-level variation in peripheral nerve block utilisation for hip fracture surgery: a population-based cross-sectional study. Br J Anaesth 2021; 128:198-206. [PMID: 34794768 DOI: 10.1016/j.bja.2021.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Unwarranted variation in anaesthesia practice is associated with adverse outcomes. Despite high-certainty evidence of benefit, a minority of hip fracture surgery patients receive a peripheral nerve block. Our objective was to estimate variation in peripheral nerve block use at the hospital, anaesthetist, and patient levels, while identifying predictors of peripheral nerve block use in hip fracture patients. METHODS After protocol registration (https://osf.io/48bvp/), we conducted a population-based cross-sectional study using linked administrative data in Ontario, Canada. We included adults >65 yr of age having emergency hip fracture surgery from April 1, 2012 to March 31, 2018. Logistic mixed models were used to estimate the variation in peripheral nerve block use attributable to hospital-, anaesthetist-, and patient-level factors with use of peripheral nerve block, quantified using the variance partition coefficient and median odds ratio. Predictors of peripheral nerve block use were estimated and temporally validated. RESULTS Of 50 950 patients, 9144 (18.5%) received a peripheral nerve block within 1 day of surgery. Patient-level factors accounted for 14% of variation, whereas 42% and 44% were attributable to the hospital and anaesthetist providing care, respectively. The median odds ratio for receiving a peripheral nerve block was 5.73 at the hospital level and 5.97 at the anaesthetist level. No patient factors had large associations with receipt of a peripheral nerve block (odds ratios significant at the 5% level ranged from 0.86 to 1.35). CONCLUSIONS Patient factors explain the minimal variation in peripheral nerve block use for hip fracture surgery. Interventions to increase uptake of peripheral nerve blocks for hip fracture patients will likely need to focus on structures and processes at the hospital and anaesthetist levels.
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Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Gavin M Hamiltoon
- ICES, Toronto, ON, Canada; Department of Anesthesiology, Queensway Carleton Hospital, Ottawa, ON, Canada
| | - Reva Ramlogan
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada
| | - Duminda N Wijeysundra
- ICES, Toronto, ON, Canada; Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Colin J L McCartney
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; ICES, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Ottawa Hospital, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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12
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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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13
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Anterior suprascapular nerve block versus interscalene brachial plexus block for arthroscopic shoulder surgery: a systematic review and meta-analysis of randomized controlled trials. J Anesth 2021; 36:17-25. [PMID: 34533639 DOI: 10.1007/s00540-021-03000-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
This systematic review aimed to compare the analgesic effectiveness and complications rates for anterior suprascapular nerve blocks (ASSB) compared to interscalene brachial plexus blocks (ISB) for arthroscopic and outpatient shoulder surgery. Only randomized controlled trials (RCTs) comparing the ASSB versus ISB in the context of arthroscopic shoulder surgery were eligible for inclusion. The primary outcomes included pain scores (Numeric Rating Scale of 0 to 10) up to 24 h postoperatively and analgesic consumption. Secondary outcomes included block complications. Meta-analysis was performed using random-effects modeling and result certainty was determined using the GRADEpro tool. Six RCTs (709 patients) were included for analysis. ISB displayed a statistically significant reduction in pain scores by 0.40 (95%CI = 0.36 to 0.45; p < 0.00001) but not morphine equivalent consumption (mean difference = 0.74 mg; 95%CI = - 0.18 to 1.66 mg; I2 = 60%; p = 0.11; moderate certainty) immediately in the postoperative care unit. Opioid consumption and pain scores at 6 to 24 h were not significantly different. There was no difference in respiratory events postblock. ASSB demonstrated a significantly lower incidence of Horner's syndrome (relative risk (RR) = 0.17; 95%CI = 0.08 to 0.39; p < 0.00001; high certainty), voice hoarseness (RR = 0.24; 95%CI = 0.10 to 0.57; p < 0.00001; high certainty) and impaired respiratory function (p < 0.00001). The ASSB could be considered an appropriate analgesic option for arthroscopic shoulder surgery with potentially fewer complications than the ISB.
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14
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Peripheral Nerve Blocks and Potentially Attributable Adverse Events in Older People with Hip Fracture: A Retrospective Population-based Cohort Study. Anesthesiology 2021; 135:454-462. [PMID: 34237127 DOI: 10.1097/aln.0000000000003863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Peripheral nerve blocks are being used with increasing frequency for management of hip fracture-related pain. Despite converging evidence that nerve blocks may be beneficial, safety data are lacking. This study hypothesized that peripheral nerve block receipt would not be associated with adverse events potentially attributable to nerve blocks, as well as overall patient safety incidents while in hospital. METHODS This was a preregistered, retrospective population-based cohort study using linked administrative data. This study identified all hip fracture admissions in people 50 yr of age or older and identified all nerve blocks (although we were unable to ascertain the specific anatomic location or type of block), potentially attributable adverse events (composite of seizures, fall- related injuries, cardiac arrest, nerve injury), and any patient safety events using validated codes. The study also estimated the unadjusted and adjusted association of nerve blocks with adverse events; adjusted absolute risk differences were also calculated. RESULTS In total, 91,563 hip fracture patients from 2009 to 2017 were identified; 15,631 (17.1%) received a nerve block, and 5,321 (5.8%; 95% CI, 5.7 to 6.0%) patients experienced a potentially nerve block-attributable adverse event: 866 (5.5%) in patients with a block and 4,455 (5.9%) without a block. Before and after adjustment, nerve blocks were not associated with potentially attributable adverse events (adjusted odds ratio, 1.05; 95% CI, 0.97 to 1.15; and adjusted risk difference, 0.3%, 95% CI, -0.1 to 0.8). CONCLUSIONS The data suggest that nerve blocks in hip fracture patients are not associated with higher rates of potentially nerve block-attributable adverse events, although these findings may be influenced by limitations in routinely collected administrative data. EDITOR’S PERSPECTIVE
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Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Cohen E, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P, Turnbull D. A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2021; 86:225-239. [PMID: 32118384 DOI: 10.23736/s0375-9393.20.14424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, Maggiore Polyclinic Hospital, Ca' Granda IRCCS and Foundation, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University Hospital, Rome, Italy
| | - Edmond Cohen
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri Mondor University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anaesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
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16
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Johnston DF, Turbitt LR. Defining success in regional anaesthesia. Anaesthesia 2021; 76 Suppl 1:40-52. [PMID: 33426663 DOI: 10.1111/anae.15275] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2020] [Indexed: 12/13/2022]
Abstract
Utilisation of regional anaesthesia is increasing globally; however, it remains challenging to determine the overall benefit of individual regional anaesthesia procedures. Like any peri-operative intervention, the benefit to the patient and healthcare system must outweigh any patient risk or resource implications. This review aims to identify markers of success in regional anaesthesia, categorise these into an objective framework and rationalise suggestions on how measuring outcomes in regional anaesthesia can be used to develop the widespread performance of this evolving subspecialty. This framework of measuring success of regional anaesthesia contains four pillars: patient-centred, population-centred, healthcare-centred and training-centred outcomes. Each pillar of success contains several outcomes which provide a structure for the measurement and development of regional anaesthesia success on a global scale.
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Affiliation(s)
- D F Johnston
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - L R Turbitt
- Department of Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK
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17
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Peripheral nerve blockade and novel analgesic modalities for ambulatory anesthesia. Curr Opin Anaesthesiol 2020; 33:760-767. [DOI: 10.1097/aco.0000000000000928] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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18
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Subomohyoid-Suprascapular versus Interscalene Block: Comment. Anesthesiology 2020; 133:948. [PMID: 32701570 DOI: 10.1097/aln.0000000000003467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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A National Registry Analysis of the Association of Perioperative Regional Anesthesia with hospital length of stay following open reduction and internal fixation of the ankle. J Clin Anesth 2020; 67:110008. [PMID: 32829110 DOI: 10.1016/j.jclinane.2020.110008] [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: 05/07/2020] [Revised: 07/22/2020] [Accepted: 07/24/2020] [Indexed: 10/23/2022]
Abstract
STUDY OBJECTIVES To evaluate if using regional anesthesia for post-operative pain control for patients who underwent ankle ORIF is associated with a decrease in length of stay. DESIGN Multicenter retrospective cohort study. SETTING Inpatient perioperative. PATIENTS 12,468 inpatients (2007 to 2016) who received ankle ORIF with and without regional anesthesia for pain control. INTERVENTIONS Regional Anesthesia for postoperative pain control. MEASUREMENTS Hospital length of stay along with multiple covariates. MAIN RESULTS The median [quartiles] hospital length of stay of the non-regional anesthesia and regional anesthesia cohorts were 1 day [0, 2 days] and 0 days [0, 1 day], respectively (p < 0.0001). On multivariable Cox regression analysis, the use of regional anesthesia was associated with decreased time to hospital discharge (HR 1.09, 95% CI 1.03-1.14, p = 0.002). Using 1:2 propensity score matching, the median [quartiles] hospital length of stay between the non-regional anesthesia and regional anesthesia matched cohorts were 0 days [0, 1 day] (range = 0-56 days) and 0 day [0, 1 day] (range = 0-33 days), respectively (p = 0.013). CONCLUSION The use of regional anesthesia for post-operative pain control was associated with a decreased length of stay for patients undergoing ankle ORIF.
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Muñoz-Leyva F, Cubillos J, Chin KJ. Managing rebound pain after regional anesthesia. Korean J Anesthesiol 2020; 73:372-383. [PMID: 32773724 PMCID: PMC7533186 DOI: 10.4097/kja.20436] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/19/2022] Open
Abstract
Rebound pain after regional anesthesia can be defined as transient acute postoperative pain that ensues following resolution of sensory blockade, and is clinically significant, either with regard to the intensity of pain or the impact on psychological well-being, quality of recovery, and activities of daily living. Current evidence suggests that it represents an unmasking of the expected nociceptive response in the absence of adequate systemic analgesia, rather than an exaggerated hyperalgesic phenomenon induced by local anesthetic neural blockade. In the majority of patients, it does not appear to significantly impact cumulative postoperative opioid consumption, quality of recovery, or patient satisfaction, and is not associated with longer-term sequelae such as persistent post-surgical pain. Nevertheless, it must be considered whenever regional anesthesia is incorporated into perioperative management. Strategies to mitigate the impact of rebound pain include routine prescribing of a systemic multimodal analgesic regimen, as well as patient education on appropriate expectations regarding block offset and expected surgical pain, and timely initiation of analgesic medication. Prolonging the duration of action of regional anesthesia with continuous catheter techniques or local anesthetic adjuncts may also help alleviate rebound pain, although further research is required to confirm this.
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Affiliation(s)
- Felipe Muñoz-Leyva
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Javier Cubillos
- Department of Anesthesia and Perioperative Medicine, University Hospital, London Health Sciences Center, Western University, London, ON, Canada
| | - Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
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21
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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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Beletsky A, Burton BN, Swisher MW, Finneran IV JJ, Gabriel RA. Utilization of regional anesthesia for open reduction and internal fixation of clavicular fractures is associated with increased same-day discharge and not readmissions. Reg Anesth Pain Med 2020; 45:716-719. [DOI: 10.1136/rapm-2020-101567] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/15/2020] [Accepted: 06/18/2020] [Indexed: 11/04/2022]
Abstract
BackgroundRegional anesthesia is becoming increasingly used for analgesia in clavicular surgery. The purpose of the study is to examine same-day discharge and readmissions in patients with clavicular fractures receiving open reduction and internal fixation, comparing those who received regional anesthesia to those that did not.MethodsThe National Surgical Quality Improvement Program registry was used to build a retrospective cohort with the primary and secondary outcomes of same-day discharge and readmission rates, respectively. The independent variable was type of anesthesia (ie, regional vs general). Unadjusted univariable followed by multivariable logistic regression analysis for the association of each covariate with the primary and secondary outcome was performed. A p<0.05 was considered statistically significant.ResultsA total of 2300 patients were included, in which 346 (15.0%) of received a nerve block. The only factor associated with same-day discharge on crude analysis was the use of a nerve block (OR 1.70, 95% CI 1.21 to 2.40, p<0.01). Factors not associated with same-day discharge included geriatric age (OR 0.39, 95% CI 0.26 to 0.57, p<0.01), diabetes mellitus (OR 0.54, 95% CI 0.33 to 0.89, p=0.01), dependent functional status (OR 0.27, 95% CI 0.11 to 0.69, p<0.01), hypertension (OR 0.39, 95% CI 0.29 to 0.52, p<0.01), bleeding disorder (OR 0.24, 95% CI 0.10 to 0.59, p<0.01) and an American Society of Anesthesiologists Physical Status score ≥3 (OR 0.33, 95% CI 0.25 to 0.45, p<0.01). On adjusted analysis, regional anesthesia was associated with increased odds of same-day discharge (OR 1.67, 95% CI 1.18 to 2.37, p<0.01), but not 30-day readmission (OR 0.57, 95% CI 0.13 to 2.52, p=0.46).ConclusionRegional anesthesia use in patients with clavicular fractures is associated with higher odds for same-day discharge. There is no significant difference in the rates of hospital readmission within a 30-day period.Level of EvidenceIV, retrospective case series.
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Abstract
PURPOSE OF REVIEW The present review aims to address the feasibility of opioid free anesthesia (OFA). The use of opioids to provide adequate perioperative pain management has been a central practice of anesthesia, and only recently has been challenged. Understanding the goals and challenges of OFA is essential as the approach to intraoperative analgesia and postsurgical management of pain has shifted in response to the opioid epidemic in the United States. RECENT FINDINGS OFA is an opioid sparing technique, which focuses on multimodal or balanced analgesia, relying on nonopioid adjuncts and regional anesthesia. Enhanced recovery after surgery protocols, often under the auspices of a perioperative pain service, can help guide and promote opioid reduced and OFA, without negatively impacting perioperative pain management or recovery. SUMMARY The feasibility of OFA is evident. However, there are limitations of this approach that warrant discussion including the potential for adverse drug interactions with multimodal analgesics, the need for providers trained in regional anesthesia, and the management of pain expectations. Additionally, minimizing opioid use perioperatively also requires a change in current prescribing practices. Monitors that can reliably quantify nociception would be helpful in the titration of these analgesics and enable anesthesiologists to achieve the goal in providing personalized perioperative medicine.
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Neuman MD, Elkassabany NM, Ochroch J, Newcomb C, Brensinger C, Mehta S, Gaskins LJ, Lane-Fall MB. Nerve Block Use after Hip Fracture Versus Elective Hip or Knee Arthroplasty: Retrospective Analysis. J Am Geriatr Soc 2020; 68:835-840. [PMID: 32124973 DOI: 10.1111/jgs.16362] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Although peripheral nerve blocks are associated with improved pain control and end outcomes among older adults with hip fracture, their current utilization among US hip fracture patients is not well understood. We characterized contemporary use of peripheral nerve blocks after hip fracture over time and identified predictors of nerve block receipt. DESIGN Retrospective cohort study of claims data from one large national private US insurer. SETTING US acute care hospitals. PARTICIPANTS A total of 94 985 adults aged 50 years and older hospitalized for a femoral neck, intertrochanteric, or subtrochanteric fracture; 409 263 adults aged 50 years and older hospitalized for elective hip or knee arthroplasty between 2004 and 2016. MEASUREMENTS Receipt of a peripheral nerve block for pain control, based on Current Procedural Terminology codes in physician service claims. RESULTS Overall, 2874 hip fracture patients (3.0%; 95% confidence interval [CI] = 2.9-3.1) received a nerve block for pain control, and the percentage receiving a block increased from .4% in 2004-2006 (95% CI = .3%-.6%) to 4.6% in 2013-2016 (95% CI = 4.4%-4.8%; P < .001). The adjusted odds of receiving a nerve block was lower for patients with vs without dementia (odds ratio [OR] = .88; 95% CI = .80-.98; P = .02) and among patients aged 75 to 84 vs 64 years or younger (OR = .86; 95% CI = .74-1.00; P = .02). The odds of nerve block receipt did not vary according to race, ethnicity, fracture location, or most other common comorbidities. Compared with patients with hip fracture, the adjusted odds of nerve block receipt were 2 times higher among patients undergoing elective hip replacement and more than 30 times higher among patients undergoing elective knee replacement. CONCLUSION Although use of peripheral nerve blocks for pain control after hip fracture has increased over time, fewer than 5 of every 100 patients hospitalized with hip fracture currently receive a peripheral nerve block, suggesting possible underuse. J Am Geriatr Soc 68:835-840, 2020.
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Affiliation(s)
- Mark D Neuman
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Department of Medicine, Division of Geriatric Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Nabil M Elkassabany
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jason Ochroch
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Craig Newcomb
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Colleen Brensinger
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Samir Mehta
- Department of Orthopedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Lakisha J Gaskins
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Meghan B Lane-Fall
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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McIsaac DI. Real-world evaluation of enhanced recovery after surgery: big data under the microscope. Br J Anaesth 2020; 124:510-512. [PMID: 32115185 DOI: 10.1016/j.bja.2020.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine and School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, ON, Canada.
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