Regional Anaesthesia Is Associated with Shorter Postanaesthetic Care and Less Pain Than General Anaesthesia after Upper Extremity Surgery

Regional anesthesia for geriatric population

Advancements in modern health care over 20 years have substantially increased the average lifespan in developed countries, and the fastest growing population is the elderly population. The proportion of people in Saudi Arabia aged 60 or more is predicted to be 25 percent of the total population of 40 million by the end of 2050. Moreover, the number of people aged 80 or more is expected to reach 1.6 million or 4 percent of the total population in the same period. Improvements in surgical techniques, anesthesia, and intensive care units make surgical interventions in older and sicker patients possible. It is estimated that over half of the population older than 65 years will require surgical intervention at least once during the remainder of their lives. Therefore, elderly patients are becoming an even larger part of anesthetic practice. Regional anesthesia (RA) is frequently used in elderly patients, especially during orthopedic surgery, genitourologic and gynecologic procedures, and hernia repair. Although age can no longer be considered a contraindication to anesthesia and surgery, anesthesia-related morbidity and mortality remain higher among elderly than among young adult surgical patients. Undoubtedly, peripheral nerve (PN) blocks improve analgesia and reduce opioid consumption and their associated side effects. This is beneficial in the perioperative care of elderly patients who may have less physiologic reserve to withstand the side effects of general anesthesia (GA).

Effect of peripheral nerve blocks on postanesthesia care unit length of stay in patients undergoing ambulatory surgery: a retrospective cohort study

BACKGROUND

Peripheral regional anesthesia and analgesia may increase the efficiency of ambulatory surgical centers by reducing pain and preventing nausea and vomiting, which are important modifiable causes of prolonged postanesthesia care unit (PACU) length of stay. We hypothesized that the use of peripheral nerve blocks (PNB) was associated with shorter PACU length of stay in ambulatory surgery.

METHODS

In this retrospective cohort study, we analyzed data from adult ambulatory surgical cases, in which PNB was a viable anesthetic option (ie, was routinely performed for these procedures), at an academic medical center between 2008 and 2018. We assessed the association between the use of PNB and the primary endpoint of PACU length of stay. As key secondary endpoint, we compared intraoperative opioid doses. Analyses were adjusted for patient demographics, comorbidities and intraoperative factors.

RESULTS

A total of 57 040 cases were analyzed, of whom 13 648 (23.9%) received a PNB. The use of PNB was associated with shorter PACU length of stay (a decrease of 7.3 min, 95% CI 6.1 to 8.6, p<0.001). This association was most pronounced in surgeries of long duration (decrease of 11.2 min, 95% CI 9.0 to 13.4) and in patients undergoing leg and ankle procedures (decrease of 15.1 min, 95% CI 5.5 to 24.6). Intraoperative opioid doses were significantly lower in patients receiving a nerve block (decrease of 9.40 mg oral morphine equivalents, 95% CI 8.34 to 10.46, p<0.001).

CONCLUSION

The use of PNB significantly reduced PACU length of stay in ambulatory surgical patients, which may in part be attributed to lower intraoperative opioid requirements.

Integrating a Cadaver Review Session into the Existing Regional Anesthesia Training for Anesthesiology Residents: An Initial Experience

The Department of Anesthesiology's Acute Pain Service (APS) places ultrasound-guided peripheral nerve blocks (PNBs) to manage acute peri-operative pain. PNB success is dependent on detailed anatomical knowledge which residents may not have formally reviewed since medical school. This study describes the integration of a cadaver review session (CRS) that reintroduces PNB-related anatomy into the existing APS rotation. During each CRS, an anatomist reviewed the major nerve and surrounding structures, while an APS attending integrated the anatomy with PNB techniques. During the pilot, 1st- and 3rd-year clinical anesthesia (CA) residents (9 CA1s, 7 CA3s) completed pre- and post-session surveys and rated the CRS's perceived value and impact on self-confidence with anatomical knowledge. Following the pilot, an additional 17 CA1s and 9 CA3s participated in the CRS and completed post-session surveys. Descriptive statistics were used to summarize responses and unpaired t tests were used to compare pre- and post-session responses and responses between cohorts. All participants were overwhelmingly positive about the CRS and its value to the APS rotation, with 98% agreeing they recommend the CRS and found it accessible. Residents believed participation would improve board exam (average = 4.83 ± 0.66) and clinical performance (average = 4.86 ± 0.65), and self-reported increases in confidence with anatomical knowledge. Residents in the pilot group reported significantly greater confidence (p < 0.01) in their perceived anatomical knowledge after the CRS. The CRS positively impacted resident confidence in their anatomical knowledge and perceived ability to identify anatomical structures. Residents reported the CRS was a highly valued addition to regional anesthesia training.

The Effect of Intraoperative Methadone Compared to Morphine on Postsurgical Pain: A Meta-Analysis of Randomized Controlled Trials

Methods

We performed a quantitative systematic review of randomized controlled trials in PubMed, Embase, Cochrane Library, and Google Scholar electronic databases. Meta-analysis was performed using the random effects model, weighted mean differences (WMD), standard deviation, 95% confidence intervals, and sample size. Methodological quality was evaluated using Cochrane Collaboration's tool.

Results

Seven randomized controlled trials evaluating 337 patients across different surgical procedures were included. The aggregated effect of intraoperative methadone on postoperative opioid consumption did not reveal a significant effect, WMD (95% CI) of −0.51 (−1.79 to 0.76), (P=0.43) IV morphine equivalents. In contrast, the effect of methadone on postoperative pain demonstrated a significant effect in the postanesthesia care unit, WMD (95% CI) of −1.11 (−1.88 to −0.33), P=0.005, and at 24 hours, WMD (95% CI) of −1.35 (−2.03 to −0.67), P < 0.001.

Conclusions

The use of intraoperative methadone reduces postoperative pain when compared to morphine. In addition, the beneficial effect of methadone on postoperative pain is not attributable to an increase in postsurgical opioid consumption. Our results suggest that intraoperative methadone may be a viable strategy to reduce acute pain in surgical patients.