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Periañez CAH, Castillo-Diaz MA, Barbosa MH, De Mattia AL. Pain Predictors in Patients in the Postanesthesia Care Unit. J Perianesth Nurs 2024; 39:652-658. [PMID: 38310508 DOI: 10.1016/j.jopan.2023.11.010] [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: 04/12/2023] [Revised: 11/07/2023] [Accepted: 11/13/2023] [Indexed: 02/05/2024]
Abstract
PURPOSE To analyze the effects of pain-predicting factors on patients in the postanesthesia care unit (PACU). DESIGN This is an observational and prospective study. METHODS This study was conducted at a University Hospital in the state of Minas Gerais (Brazil). To collect data on demographic, clinical, and surgical factors, a collection instrument was devised. The verbal numerical scale was employed to measure pain levels before and after surgery in the PACU. A path analysis was used to assess a predictive model. FINDINGS A total of 226 patients were included in this study. The incidence of pain in the PACU was 31.9%. A model with demographic, clinical, and surgical variables was tested. The final model, after including modification indices, obtained results that indicated an acceptable data fit (comparative fit index = 0.996; root mean square error of approximation = 0.08). Age (being young), sex (being a woman), oncological diagnosis as an indication for the surgical procedure, type of surgery (surgery of the digestive system), duration of surgery (longer surgeries), and high intraoperative doses of opioids were predictive variables for pain in the PACU. CONCLUSIONS This study's findings provide support for pain management in the PACU. Furthermore, the results of this research can be used to anticipate the occurrence of acute postoperative pain and personalized perioperative analgesia needs.
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Affiliation(s)
| | - Marcio Alexander Castillo-Diaz
- Universidad Nacional Autónoma de Honduras, Vicerrectoría de Orientación y Asuntos Estudiantiles. Tegucigalpa, Francisco Morazán, Honduras
| | - Maria Helena Barbosa
- Universidade Federal do Triângulo Mineiro, Departamento de Enfermagem na Assistência Hospitalar. Uberaba, Minas Gerias, Brasil
| | - Ana Lúcia De Mattia
- Universidade Federal de Minas Gerais, Escola de Enfermagem, Departamento de Enfermagem Básica, Belo Horizonte, Minas Gerais, Brasil
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Maxwell A. Opioid-free versus opioid-sparing anaesthesia in ambulatory total hip arthroplasty. Comment on Br J Anaesth 2024; 132: 352-8. Br J Anaesth 2024; 133:453-454. [PMID: 38876924 DOI: 10.1016/j.bja.2024.04.057] [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: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 06/16/2024] Open
Affiliation(s)
- Andrew Maxwell
- Department of Anaesthesia, Intensive Care and Pain Medicine, Cork University Hospital, Cork, Ireland.
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Carlé N, Nikolajsen L, Uhrbrand CG. Respiratory Depression Following Intraoperative Methadone: A Retrospective Cohort Study. Anesth Analg 2024:00000539-990000000-00825. [PMID: 38814334 DOI: 10.1213/ane.0000000000007018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND Methadone is used as a perioperative analgesic in the management of postoperative pain. Despite positive outcomes from randomized trials favoring methadone, concerns about its safety persist, particularly regarding respiratory depression (RD) and excessive sedation. In this study, we compared the incidence of naloxone administration between patients administered intraoperative methadone and those administered intraoperative morphine as a measure of severe RD. Time spent at the postanesthesia care unit (PACU) was used as a proxy variable for excessive sedation. METHODS This was a retrospective cohort study including all patients aged ≥18 years who underwent surgery between March 2019 and March 2023 at Aarhus University Hospital, Denmark. We assessed the association between intraoperative administration of either methadone or morphine and postoperative naloxone administration within the first 24 hours using logistic regression (primary outcome). An analogous linear regression model was used for the secondary outcome of time spent in the PACU after surgery. Patients were weighted using propensity scores to adjust for potential confounding variables. RESULTS A total of 14,522 patients were included in the analysis. Among the 2437 patients who received intraoperative methadone, 15 (0.62%) patients received naloxone within the first 24 hours after surgery compared to 68 of 12,0885 (0.56%) who received intraoperative morphine. No statistical difference was observed in the odds of naloxone administration between patients administered methadone or morphine (adjusted odds ratio 95% confidence interval [CI], 1.21 [0.40-2.02]). Patients who were administered intraoperative methadone had a mean PACU length of stay (LOS) of 334 minutes (standard deviation [SD], 382) compared to 195 minutes (SD, 228) for those administered intraoperative morphine. The adjusted PACU LOS of patients administered intraoperative methadone was 26% longer compared to those administered intraoperative morphine (adjusted ratio of the geometric means 95% CI, 1.26 [1.22-1.31]). CONCLUSIONS The incidence of naloxone administration to treat severe RD was low. No difference was observed in the odds of naloxone administration to treat severe RD between patients administered intraoperative methadone or intraoperative morphine. Intraoperative methadone was associated with longer stays at the PACU; however, this result should be interpreted with care. Our findings suggest that intraoperative methadone has a safety profile comparable to that of morphine with regard to severe RD.
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Affiliation(s)
- Nicolai Carlé
- From the Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lone Nikolajsen
- From the Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Camilla G Uhrbrand
- From the Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Chen L, Glatt E, Kerr P, Weng Y, Lough ME. Stir-up Regimen After General Anesthesia in the Postanesthesia Care Unit: A Nurse Led Stepped Wedge Cluster Randomized Control Trial. J Perianesth Nurs 2024; 39:207-217. [PMID: 37978971 DOI: 10.1016/j.jopan.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 06/07/2023] [Accepted: 07/20/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To implement a standardized Stir-up Regimen (deep breathing, coughing, repositioning, mobilization [moving arms/legs], assessing and managing pain and nausea) within the first 30 minutes of arrival in the postanesthesia care unit (PACU), with a goal of decreasing recovery time in the immediate postanesthesia period (Phase I). DESIGN A pragmatic stepped wedge cluster randomized control trial. Initially, data were collected on time in Phase I in three PACUs (control). Subsequently, the same three units were randomized to sequentially transition to the Stir-up Regimen (intervention). METHODS A stepped wedge cluster randomized control trial design was used to implement a standardized Stir-up Regimen in three PACUs in an academic hospital for adult patients who received at least 30 minutes of general anesthesia. The measured outcome was the PACU time in minutes from patient arrival to when the patient met Phase I discharge criteria. Differences between intervention and control groups were evaluated using a generalized mixed-effects model. Nurses were educated about the Stir-up Regimen in team huddles, in-services, video demonstrations, email notifications and reminders, and immediate feedback at the bedside. Implementation science principles were used to assess the adoption of the Stir-up Regimen through a presurvey, postsurvey and spot-check observations in all three PACUs. FINDINGS A total of 5,809 PACU adult patient admissions were included: control group (n = 2,860); intervention group (n = 2,949); males (n = 2,602), and females (n = 3,206). The intervention was associated with a reduction in overall mean Phase I recovery time of 4.9 minutes (95% CI: -8.4 to -1.4, P = .007). One PACU decreased time by 9.6 minutes (95% CI: -15.3 to -4.0, P < .001). The other units also reduced Phase I recovery time, but this did not reach statistical significance. The spot-check observations confirmed the intervention was adopted by the nurses, as most interventions were nurse-initiated versus patient-initiated during the first 30 minutes in PACU. CONCLUSIONS Standardization of a Stir-up Regimen within 30 minutes of patient PACU arrival resulted in decreased Phase I recovery time.
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Affiliation(s)
- Ling Chen
- Interventional Platform, Stanford Health Care, Stanford, CA.
| | | | - Paul Kerr
- Interventional Platform, Stanford Health Care, Stanford, CA
| | - Yingjie Weng
- Quantitative Sciences Unit, Stanford University, Stanford, CA
| | - Mary E Lough
- Evidence Based Practice Center, Professional Practice and Clinical Improvement, Stanford Health Care, Stanford, CA; Primary Care and Population Health, School of Medicine, Stanford University, Stanford, CA
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Malachauskiené L, Bhavsar RP, Waldemar J, Strøm T. Effect of Interpectoral-Pectoserratus Plane (PECS II) Block on Recovery Room Discharge Time in Breast Cancer Surgery. MEDICINA (KAUNAS, LITHUANIA) 2023; 60:41. [PMID: 38256302 PMCID: PMC10819446 DOI: 10.3390/medicina60010041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/14/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: The increase in the incidence and diagnosis rate of breast cancer demands the optimization of resources. The aim of this study was to assess whether the supplementation of the interpectoral-pectoserratus plane block (PECS II) reduces surgery and post-anesthesia care unit (PACU) time in patients undergoing breast cancer surgery. Materials and methods: This was a retrospective data-analysis study. In 2016, PECS II block was introduced as a supplement to general anesthesia for all mastectomies with or without axillary resections in South Jutland regional hospital, Denmark. The perioperative data of patients operated 3 years before and 3 years after 2016 was retrieved through the Danish anesthesia database and patient journals and systematically analyzed. Female patients aged over 18 years, with no use of muscle relaxant, intubation, and inhalation agents, were included. The eligible data was organized into two groups, i.e., Block and Control, where the Block group received PECS II Block, while the Control group received only general anesthesia. Parameters such as surgery time, anesthesia time, PACU time, opioid consumption, and the incidence of postoperative nausea and vomiting (PONV) in PACU were retrieved and statistically analyzed. Results: A total of 172 patients out of 358 patients met eligibility criteria. After applying exclusion criteria, 65 patients were filtered out. A total of 107 patients, 51 from the Block and 56 from the Control group, were eligible for the final analysis. The patients were comparable in demographic parameters. The median surgery time was significantly less in the Block group (78 min (60-99)) in comparison to the Control group (98.5 min (77.5-139.5) p < 0.0045). Consequently, the median anesthesia time was also shorter in the Block group (140 min (115-166)) vs. the Control group (160 min (131.5 to 188), p < 0.0026). Patients from the Block group had significantly lower intraoperative fentanyl consumption (60 µg (30-100)) as compared with the Control group (132.5 µg (80-232.5), p < 0.0001). The total opioid consumption during the entire procedure (converted to morphine) was significantly lower in the Block group (16.37 mg (8-23.6)) as compared with the Control group (31.17 mg (16-46.5), p < 0.0001). No statistically significant difference was found in the PACU time, incidences of PONV, and postoperative pain. Conclusions: The interpectoral-pectoserratus plane (PECS II) block supplementation reduces surgery time, anesthesia time, and opioid consumption but not PACU time during breast cancer surgery.
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Affiliation(s)
- Laima Malachauskiené
- Department of Anesthesia and Critical Care Medicine, South Jutland Regional Hospital, Kresten Philipsens Vej 15, DK-6200 Aabenraa, Denmark; (L.M.); (T.S.)
| | - Rajesh Prabhakar Bhavsar
- Department of Anesthesia and Critical Care Medicine, South Jutland Regional Hospital, Kresten Philipsens Vej 15, DK-6200 Aabenraa, Denmark; (L.M.); (T.S.)
| | - Jacob Waldemar
- Odense Medical College, Odense University, Campusvej 55, DK-5230 Odense, Denmark;
| | - Thomas Strøm
- Department of Anesthesia and Critical Care Medicine, South Jutland Regional Hospital, Kresten Philipsens Vej 15, DK-6200 Aabenraa, Denmark; (L.M.); (T.S.)
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Rupp S, Ahrens E, Rudolph MI, Azimaraghi O, Schaefer MS, Fassbender P, Himes CP, Anand P, Mirhaji P, Smith R, Freda J, Eikermann M, Wongtangman K. Development and validation of an instrument to predict prolonged length of stay in the postanesthesia care unit following ambulatory surgery. Can J Anaesth 2023; 70:1939-1949. [PMID: 37957439 DOI: 10.1007/s12630-023-02604-1] [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: 12/21/2022] [Revised: 04/12/2023] [Accepted: 04/28/2023] [Indexed: 11/15/2023] Open
Abstract
PURPOSE We sought to develop and validate an Anticipated Surveillance Requirement Prediction Instrument (ASRI) for prediction of prolonged postanesthesia care unit length of stay (PACU-LOS, more than four hours) after ambulatory surgery. METHODS We analyzed hospital registry data from patients who received anesthesia care in ambulatory surgery centres (ASCs) of university-affiliated hospital networks in New York, USA (development and internal validation cohort [n = 183,711]) and Massachusetts, USA (validation cohort [n = 148,105]). We used stepwise backwards elimination to create ASRI. RESULTS The model showed discriminatory ability in the development, internal, and external validation cohorts with areas under the receiver operating characteristic curve of 0.82 (95% confidence interval [CI], 0.82 to 0.83), 0.82 (95% CI, 0.81 to 0.83), and 0.80 (95% CI, 0.79 to 0.80), respectively. In cases started in the afternoon, ASRI scores ≥ 43 had a total predicted risk for PACU stay past 8 p.m. of 32% (95% CI, 31.1 to 33.3) vs 8% (95% CI, 7.9 to 8.5) compared with low score values (P-for-interaction < 0.001), which translated to a higher direct PACU cost of care of USD 207 (95% CI, 194 to 2,019; model estimate, 1.68; 95% CI, 1.64 to 1.73; P < 0.001) The effects of using the ASRI score on PACU use efficiency were greater in a free-standing ASC with no limitations on PACU bed availability. CONCLUSION We developed and validated a preoperative prediction tool for prolonged PACU-LOS after ambulatory surgery that can be used to guide scheduling in ambulatory surgery to optimize PACU use during normal work hours, particularly in settings without limitation of PACU bed availability.
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Affiliation(s)
- Samuel Rupp
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- School of Medicine, Technical University of Munich, Munich, Germany
| | - Elena Ahrens
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- School of Medicine, Philipps-University Marburg, Marburg, Germany
| | - Maira I Rudolph
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology and Intensive Care Medicine, Cologne University Hospital, Cologne, Germany
| | - Omid Azimaraghi
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maximilian S Schaefer
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Philipp Fassbender
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Operative Intensive Care Medicine, Pain- and Palliative Care Medicine, Marien Hospital Herne, Ruhr-University Bochum University Hospital, Herne, Germany
| | - Carina P Himes
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Preeti Anand
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Parsa Mirhaji
- Center for Health Data Innovations, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard Smith
- Department of Otorhinolaryngology - Head & Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Jeffrey Freda
- Surgical Services, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthias Eikermann
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
- Department of Anesthesiology and Intensive Care Medicine, Duisburg-Essen University Hospital, Essen, Germany.
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Karuna Wongtangman
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Aldwikat RK, Manias E, Holmes AC, Tomlinson E, Nicholson P. Associations of postoperative delirium with activities of daily living in older people after major surgery: A prospective cohort study. J Clin Nurs 2023; 32:7578-7588. [PMID: 37341067 DOI: 10.1111/jocn.16801] [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: 09/21/2022] [Revised: 05/01/2023] [Accepted: 05/30/2023] [Indexed: 06/22/2023]
Abstract
AIMS To assess the association of postoperative delirium developed in the post-anaesthetic care unit (PACU) with older patients' ability to perform activities of daily living (ADL) during the first five postoperative days. BACKGROUND Previous studies have focused on the association between postoperative delirium and long-term function decline, however the association between postoperative delirium and the ability to perform ADL, particularly in the immediate postoperative period, needs further investigation. DESIGN A prospective cohort study. METHODS A total of 271 older patients who underwent elective or emergency surgery at a tertiary care hospital in Victoria, Australia, participated in the study. Data were collected between July 2021 and December 2021. Delirium was assessed using the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). The Katz Index of Independence in Activities of Daily Living (KATZ ADL) scale was used to measure ADL. ADL was assessed preoperatively and daily during the first five postoperative days. The STROBE checklist was used to report this study. RESULTS Results showed that 44 (16.2%) patients developed new episode of delirium. Postoperative delirium was independently associated with decline in ADL (RR = 2.83, 95% CI = 2.71-2.97; p < 0.001). CONCLUSIONS Postoperative delirium was associated with a decline in ADL among older people during the first five postoperative days. Screening for delirium in the PACU is essential to identify delirium during the early stages of postoperative period and implement a timely comprehensive plan. RELEVANCE TO CLINICAL PRACTICE Delirium assessment of older patients in the PACU, and for at least the first five postoperative days, is strongly recommended. We also recommend engagement of patients in a focused physical and cognitive daily activity plan, particularly for older patients undergoing major surgery. PATIENT OR PUBLIC CONTRIBUTION Patients and nurses helped in data collection at a tertiary care hospital.
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Affiliation(s)
- Rami K Aldwikat
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- Operating Theatre, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
- Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Alex C Holmes
- Department of Psychiatry, The University of Melbourne, Parkville, Victoria, Australia
- Department of Mental Health, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Emily Tomlinson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Deakin University, Geelong, Victoria, Australia
- Centre for Quality and Patient Safety Research, Faculty of Health, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
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Kelly-Hellyer E, Sigueza AL, Pestritto M, Clark-Cutaia MN. The Analgesic Properties of a Music Intervention in the Postanesthesia Care Unit. J Perianesth Nurs 2023; 38:763-767. [PMID: 37269276 DOI: 10.1016/j.jopan.2022.12.007] [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: 07/22/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 06/05/2023]
Abstract
PURPOSE The purpose of this study was to determine whether a combined music pharmacological intervention was an effective multimodal approach to reduce adult pain in the postanesthesia care unit (PACU). DESIGN A prospective, randomized control trial study. METHODS Participants were recruited in the preoperative holding area on the day of surgery by the principal investigators. Music was selected by the patient following the informed consent process. Participants were randomized either to the intervention group or the control group. Patients in the intervention group received music in addition to standard pharmacological protocol while the control group received only the standard pharmacological protocol. Measured outcomes were change in visual analog pain scores and length of stay. FINDINGS In this cohort (N = 134), 68 participants (50.7%) received the intervention, and 66 participants (49.3%) were in the control group. Paired t tests showed that pain scores for the control group worsened by an average of 1.45-points (95% CI: 0.75, 2.15; P < .001) compared to 0.34-points in the intervention group and was not significant (P = .314) as scores went from 1 out of 10 to 1.4 out of 10. Both control and intervention groups experienced pain, with the control group's overall pain scores worsening over time. This finding was statistically significant (P = .023). No statistically significant difference was noted in the average PACU length of stay (LOS). CONCLUSIONS The addition of music to the standard postoperative pain protocol demonstrated a lower average pain score on discharge from the PACU. The absence of a difference in LOS may be due to the confounding variables (eg, general versus spinal anesthesia or a difference in voiding time).
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Affiliation(s)
- Erin Kelly-Hellyer
- Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA
| | - Anna L Sigueza
- Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA.
| | - Mara Pestritto
- Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA
| | - Maya N Clark-Cutaia
- Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA; NYU Meyers College of Nursing, New York, NY
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Lu Y, Labott JR, Salmons Iv HI, Gross BD, Barlow JD, Sanchez-Sotelo J, Camp CL. Identifying modifiable and nonmodifiable cost drivers of ambulatory rotator cuff repair: a machine learning analysis. J Shoulder Elbow Surg 2022; 31:2262-2273. [PMID: 35562029 DOI: 10.1016/j.jse.2022.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/25/2022] [Accepted: 04/09/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Implementing novel tools that identify contributors to the cost of orthopedic procedures can help hospitals maximize efficiency, minimize waste, improve surgical decision-making, and practice value-based care. The purpose of this study was to develop and internally validate a machine learning algorithm to identify key drivers of total charges after ambulatory arthroscopic rotator cuff repair and compare its performance with a state-of-the-art statistical learning model. METHODS A retrospective review of the New York State Ambulatory Surgery and Services Database was performed to identify patients who underwent elective outpatient rotator cuff repair (RCR) from 2015 to 2016. Initial models were constructed using patient characteristics (age, gender, insurance status, patient income, Elixhauser Comorbidity Index) as well as intraoperative variables (concomitant procedures and services, operative time). These were subsequently entered into 5 separate machine learning algorithms and a generalized additive model using natural splines. Global variable importance and partial dependence curves were constructed to identify the greatest contributors to cost. RESULTS A total of 33,976 patients undergoing ambulatory RCR were included. Median total charges after ambulatory RCR were $16,017 (interquartile range: $11,009-$22,510). The ensemble model outperformed the generalized additive model and demonstrated the best performance on internal validation (root mean squared error: $7112, 95% confidence interval: 7036-7188; logarithmic root mean squared error: 0.354, 95% confidence interval: 0.336-0.373, R2: 0.53), and identified major drivers of total charges after RCR as increasing operating room time, patient income level, number of anchors used, use of local infiltration anesthesia/peripheral nerve blocks, non-White race/ethnicity, and concurrent distal clavicle excision. The model was integrated into a web-based open-access application capable of providing individual predictions and explanations on a case-by-case basis. CONCLUSION This study developed an ensemble supervised machine learning algorithm that outperformed a sophisticated statistical learning model in predicting total charges after ambulatory RCR. Important contributors to total charges included operating room time, duration of care, number of anchors used, type of anesthesia, concomitant distal clavicle excision, community characteristics, and patient demographic factors. Generation of a patient-specific payment schedule based on the Agency for Healthcare Research and Quality risk of mortality highlighted the financial risk assumed by physicians in flat episodic reimbursement schedules given variable patient comorbidities and the importance of an accurate prediction algorithm to appropriately reward high-value care at low costs.
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Affiliation(s)
- Yining Lu
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Joshua R Labott
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
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Butorphanol as an Adjuvant to Ropivacaine for Adductor Canal Blocks in Total Knee Arthroplasty Patients: A Randomized, Double, Blind Study. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:7718108. [PMID: 36275396 PMCID: PMC9586814 DOI: 10.1155/2022/7718108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/05/2022] [Indexed: 11/05/2022]
Abstract
Background The objective of this study was to observe the effects of butorphanol as an adjuvant to ropivacaine for the adductor canal block (ACB) on postoperative analgesia in patients undergoing total knee arthroplasty (TKA). Methods Seventy-four patients undergoing TKA were included and randomly divided into two groups: Group BR received 20 ml of 0.33% ropivacaine plus 1 mg butorphanol and Group R received 20 ml of 0.33% ropivacaine plus 1 ml normal saline for ultrasound-guided adductor canal blocks. The primary outcomes were the duration of the sensory block and the pain visual analogue scale (VAS), and secondary outcomes included the number of PCIA attempts (patient-controlled intravenous analgesia) and the time to first pressing and rescue analgesia. Other outcomes included knee active range of motion (ROM), quadriceps strength, the time to first mobilization, the duration of postoperative hospital stay, Knee Society Score (KSS), and postoperative complications. Results Since two patients in each group rejected postoperative assessments, 35 patients were included in each group. Compared with Group R, Group BR had longer duration of sensory blocks (18.42 ± 3.46 vs. 15.36 ± 2.29 h, p < 0.01) and lower postoperative pain scores within 24 hours at rest and within 12 hours with activity (p < 0.01). The number of PCIA attempts decreased within 48 hours after surgery (4.5 ± 1.2 vs. 7.8 ± 1.5 times, p < 0.01), and the time to first pressing was later (20.31 ± 2.59 vs. 16.25 ± 2.31 h, p < 0.01). In addition, Group BR had bigger knee ROM at within 24 hours after the operation than Group R (68.37 ± 4.70°vs. 59.21 ± 6.41,85.67 ± 5.17 vs. 74.37 ± 4.68°, 97.62 ± 5.43 vs. 84.18 ± 4.49°, p < 0.01). There was no significant difference between the two groups (p > 0.05) in terms of rescue analgesia, quadriceps strength, the time to first mobilization, the duration of postoperative hospital stay, the KSS function scores, and postoperative complications. Conclusions Butorphanol plus ropivacaine ultrasound-guided adductor canal block can prolong the duration of sensory block, relieve early postoperative pain, and improve the range of motion of the knee joint, without affecting the occurrence of postoperative complications. Name of the Registry. Chinese Clinical Trial Registry. Trial Registration Number. ChiCTR2100041859. URL of Trial Registry Record. http://www.chictr.org.cn/edit.aspx?pid=119731&htm=4. Date of Registration. 08/01/2021 0:00:00.
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Agoston AM, Bhatia A, Bleacher JC, Smith A, Hill K, Edwards S, Cochran A, Routly M. PTSD Risk Factors and Acute Pain Intensity Predict Length of Hospital Stay in Youth after Unintentional Injury. CHILDREN 2022; 9:children9081222. [PMID: 36010111 PMCID: PMC9406594 DOI: 10.3390/children9081222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/27/2022] [Accepted: 08/09/2022] [Indexed: 11/16/2022]
Abstract
Background: Many hospitals have adopted screening tools to assess risk for posttraumatic stress disorder (PTSD) after pediatric unintentional injury in accordance with American College of Surgeons recommendations. The Screening Tool for Early Predictors of PTSD (STEPP) is a measure initially developed to identify youth and parents at high risk for meeting diagnostic criteria for PTSD after injury. Acute pain during hospitalization has also been examined as a potential predictor of maladaptive outcomes after injury, including PTSD. We investigated in a retrospective cohort study whether the STEPP, as well as acute pain intensity during hospitalization, would predict maladaptive outcomes during the peri-trauma in addition to the post-trauma period, specifically length of hospitalization. Methods: A total of 1123 youths aged 8–17 (61% male) and their parents were included. Patients and parents were administered the STEPP for clinical reasons while hospitalized. Acute pain intensity and length of stay were collected through retrospective chart review. Results: Adjusting for demographics and injury severity, child but not parent STEPP total predicted length of stay. Acute pain intensity, child threat to life appraisal, and child pulse rate predicted length of stay. Conclusions: Acute pain intensity and child PTSD risk factors, most notably child threat to life appraisal, predicted hospitalization length above and beyond multiple factors, including injury severity. Pain intensity and child appraisals may not only serve as early warning signs for maladaptive outcomes after injury but also indicate a more difficult trajectory during hospitalization. Additional assessment and treatment of these factors may be critical while youth are hospitalized. Utilizing psychology services to support youth and integrating trauma-informed care practices during hospitalization may support improved outcomes for youth experiencing unintentional injury.
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Affiliation(s)
- Anna Monica Agoston
- Center for Pain Relief, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
- Division of Pediatric Anesthesiology, Emory University, Atlanta, GA 30322, USA
- Correspondence: ; Tel.: +1-503-830-4305; Fax: +1-404-785-6223
| | - Amina Bhatia
- Division of Surgery, Emory University, Atlanta, GA 30322, USA
| | - John C. Bleacher
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Alexis Smith
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Karen Hill
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Susanne Edwards
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Alicia Cochran
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
| | - Maia Routly
- Division of Trauma Services, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA
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Sublingual Sufentanil vs. Intravenous Fentanyl for the Treatment of Acute Postoperative Pain in the Ambulatory Surgery Center: A Randomized Clinical Trial. Anesthesiol Res Pract 2022; 2022:5237877. [PMID: 35844809 PMCID: PMC9286986 DOI: 10.1155/2022/5237877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 06/17/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives Sublingual sufentanil is a novel opioid medication to treat moderate to severe pain postoperatively. This study's aim was to determine if a single dose of a sublingual sufentanil tablet (SST) is as efficacious as a single dose of intravenous (IV) fentanyl in readiness to discharge from ambulatory surgery. Methods This was a two-arm, parallel group, randomized prospective outcomes study conducted at a single, free-standing ambulatory surgery center. Patients aged 18–80 undergoing general anesthesia who developed a postoperative pain score of ≥ 4 were enrolled and randomized to receive either 30 mcg SST or 50 mcg IV fentanyl. After their initial randomized dose, rescue IV fentanyl followed by oral oxycodone if needed. Recovery length of stay from arrival in the postanesthesia care unit until readiness to discharge criteria was met based on phase 2 discharge criteria. Results 75 patients were analyzed. Readiness to discharge from the recovery room was not significantly different between either group (IV fentanyl median 65 minutes; IQR 56–89; SST 73 min, IQR 58–89; p=0.903). There was no significant difference in the amount of morphine equivalents (MME) of rescue opioids needed (IV fentanyl median rescue MME of 22.5, IQR 13.1–23.4; SST median rescue MME of 15.0, IQR 7.5–30.0; p=0.742). The change in pain from PACU initially, and on discharge was not significantly different (IV fentanyl initial pain minus pain on discharge median 3, IQR 2–4; SST initial pain minus pain on discharge median 4, IQR 2–5.5; p=0.079). There was no difference in the six-item screener and the Overall Benefit of Analgesic Survey Score. Discussion. In conclusion, patients who received a sublingual sufentanil 30 mcg tablet had no significant differences in PACU length of stay or rescue analgesic usage when compared to intravenous fentanyl 50 mcg.
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KULA ŞAHİN S, ŞELİMEN HD. Evaluation of Complication Development in General Surgery Patients Admitted to the Post Anesthesia Care Unit. CLINICAL AND EXPERIMENTAL HEALTH SCIENCES 2022. [DOI: 10.33808/clinexphealthsci.892276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Seify H. Sufentanil Sublingual Tablet Reduces Postoperative Opioid Use Following Outpatient Plastic Surgery. Aesthet Surg J Open Forum 2022; 4:ojac040. [PMID: 35747464 PMCID: PMC9212086 DOI: 10.1093/asjof/ojac040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The emphasis on better pain control with less narcotic use represents an ongoing challenge for outpatient plastic surgery procedures. Intravenous (IV) bolus opioids during surgery can lead to short-term relief, but often repeat dosing is required in the postanesthesia care unit (PACU), prolonging recovery time. The sufentanil sublingual tablet (SST) has recently shown efficacy in reducing overall opioid use and postsurgical recovery time for outpatient general surgery procedures. Objectives To examine the effect of SST on PACU opioid use, adverse events, and recovery time compared with traditional IV opioid drug regimens in patients undergoing aesthetic surgical procedures. Methods A retrospective chart review was performed on SST patients (n = 61) receiving a single 30 mcg SST 30 minutes before surgery (for short procedures) or 45 minutes before surgical extubation (longer procedures). A control group (n = 32) underwent similar surgical procedures utilizing standard IV opioid treatment without SST. Results Control and study groups were of similar age and sex. Procedure duration (approximately 3 hours) and intraoperative opioid administration were similar in both groups, with 92% of patients receiving SST before extubation due to the length of the case. Almost all control patients (90.6%) required rescue opioids during recovery in the PACU compared with a few SST patients (16.4%; P < 0.001), averaging 5-fold higher dosing in the control group. Recovery duration did not differ between groups as factors other than pain management and adverse events affected discharge. Conclusions SST substantially reduced opioid administration in the PACU for patients undergoing outpatient plastic surgery procedures. Level of Evidence 3
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Affiliation(s)
- Hisham Seify
- Corresponding Author:Dr Hisham Seify, Newport Plastic Surgery, 20301 SW Birch St, Suite 100, Newport Beach, CA 92660, USA. E-mail: ; Instagram: @newportplastic
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Kazum E, Rath E, Shlaifer A, Sharfman ZT, Martin HD, Eizenberg G, Reider E, Amar E. Preemptive analgesia in hip arthroscopy: intra-articular bupivacaine does not improve pain control after preoperative peri-acetabular blockade. Hip Int 2022; 32:265-270. [PMID: 32866047 DOI: 10.1177/1120700020950247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Literature addressing postoperative pain management after hip arthroscopy is relatively scarce. This study aimed to assess if there was added analgesic benefit associated with postoperative intra-articular bupivacaine blockade for patients who received preoperative peri-acetabular blockade for hip arthroscopy procedures. METHODS 52 patients were included in this comparative cohort study. Group 1 consisted of 20 patients who received preoperative peri-acetabular blockade and postoperative intra-articular blockade. The control group (Group 2), consisted of 32 patients who received only preoperative peri-acetabular blockade. Postoperative pain was recorded via visual analogue scale (VAS) pain scores, analgesic consumption, and pain diaries for 2 weeks postoperatively. RESULTS Postoperative VAS pain scores were significantly lower in the experimental group at the 30-minute recovery room assessment (VAS scores Group 1: 1.1; Group 2: 3.00, p = 0.034). Other than the 30-minute recovery room assessment, VAS pain scores, narcotic medication consumption, and non-narcotic analgesic consumption did not differ between the 2 groups at any time point in the study period. CONCLUSIONS This study did not demonstrate significant clinical benefit for patients who receive postoperative intra-articular blockade in addition to preoperative peri-acetabular blockade with bupivacaine 0.5%. We recommend the use of preoperative peri-acetabular bupivacaine blockade without intra-articular blockade postoperatively for pain control in the setting of hip arthroscopy surgery.
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Affiliation(s)
- Efi Kazum
- Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Rath
- Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Amir Shlaifer
- Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zachary T Sharfman
- Department of Orthopedic Surgery, Montefiore Medical Center and The Albert Einstein College of MedicineBronx, NY, USA
| | - Hal D Martin
- Hip Preservation Center, Baylor University Medical Center, Dallas, TX, USA
| | - Gilad Eizenberg
- Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Evgeny Reider
- Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Amar
- Department of Orthopaedic Surgery, Tel Aviv Sourasky Medical Center, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Nimmaanrat S, Geater A, Plunsangkate P, Saewong L, Karnjanawanichkul O, Chanchayanon T, Pattaravit N. ABO blood group is not a predictive factor for the amount of early opioid consumption in postanesthesia care unit: a prospective cohort study in 3,316 patients. BMC Anesthesiol 2022; 22:48. [PMID: 35172725 PMCID: PMC8848900 DOI: 10.1186/s12871-022-01583-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 01/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background Immediate postoperative pain in the postanesthesia care unit (PACU) is common. Titration of opioid is the most popular strategy for controlling early postoperative pain. ABO blood group has been found to be associated with pain perception. We aimed to find the factors including ABO blood group for predicting the amount of opioid requirement in PACU. Methods This prospective cohort study was performed in 3316 patients who underwent various kinds of anesthetic techniques and received immediate postoperative care in PACU. Preoperative, intraoperative and PACU data were collected. A directed acyclic graph (DAG) representing the hypothesized causal pathways of preoperative, intraoperative and PACU data were compiled prior to conducting multinomial logistic regression analysis. Statistical significance in all models was defined as a P-value < 0.05. Results Female sex, body mass index, preoperative use of gabapentin, preoperative anxiety score, anesthetic techniques, type of operation, amount of consumed intraoperative opioids, intraoperative use of paracetamol, parecoxib and ondansetron, duration of anesthesia and surgery, amount of blood loss, pain upon PACU arrival, use of paracetamol and parecoxib in PACU were found to be factors influencing amount of opioid consumption in PACU. ABO blood group was not associated with early postoperative opioid requirement. Conclusions A significant number of factors are related to amount of opioid requirement in PACU. Some factors can be adjusted to provide better pain relief in early postoperative period. However, ABO blood group is not identified to be a predictive factor for early postoperative opioid consumption in PACU.
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Affiliation(s)
- Sasikaan Nimmaanrat
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Alan Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Prae Plunsangkate
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Laortip Saewong
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Orarat Karnjanawanichkul
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Thavat Chanchayanon
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Ngamjit Pattaravit
- Department of Anesthesiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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Bloom L, Mazzella A, Flynn J, Panageas K. Symptoms, Surgical Events, and Length of Stay of Surgical Oncology Outpatients. J Perianesth Nurs 2022; 37:204-209. [PMID: 35067410 PMCID: PMC9392871 DOI: 10.1016/j.jopan.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 04/09/2021] [Accepted: 04/11/2021] [Indexed: 11/18/2022]
Abstract
PURPOSE This study examined the incidence of postanesthesia symptoms, postoperative events, and length of stay (LOS) for surgical oncology outpatients in Phase II recovery during three time periods: before, one-month post, and one-year after the implementation of revised PACU I to PACU II transfer procedures and discharge criteria. DESIGN Data for this retrospective analysis was obtained from the organizations' electronic medical records during the timeframe April 3, 2017 through August 5, 2018 after enhanced PACU I to PACU II transfer procedures were implemented on June 5, 2017. Records of surgical outpatients transferred from PACU I to PACU II who received regional pain control or preoperative anti-emetics were excluded from the analysis. METHODS Study approval was obtained through the Institutional Review Board [#19-308]. The records [n = 1091] were sorted and analyzed according to symptoms, events, and length of recovery. Incidence of symptoms, use of IV fluids, and medications administered in PACU II was tabulated for each time-period. Kruskal-Wallis tests were used to detect differences in length of stay variables across the three time periods. FINDINGS A significant decrease in PACU II LOS was observed following the implementation of revised PACU I to PACU II transfer criteria (P< .001). Although blood pressure changes decreased between each time period: 1.4% (T-1), 0.3% (T-2), and 0.2% (T-3), postanesthesia symptoms [dizziness, pain, and nausea] decreased from T-1 to T-2, with a small increase in T-3. The use of fentanyl and continuous IV fluids decreased between all time periods. CONCLUSIONS Monitoring key variables related to patient outcomes involving LOS and symptom management ensures sustained practice changes, improves care, and optimizes surgical outpatient experience.
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Affiliation(s)
- Linda Bloom
- Department of Nursing Perioperative Services, Memorial Sloan Kettering Cancer Center, New York, NY.
| | - AnnMarie Mazzella
- Office of Nursing Research, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jessica Flynn
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Katherine Panageas
- Department of Epidemiology-Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY
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The Evaluation Point-of-Care Ultrasound in the Post-Anesthesia Unit-A Multicenter Prospective Observational Study. J Clin Med 2021; 10:jcm10112389. [PMID: 34071466 PMCID: PMC8198895 DOI: 10.3390/jcm10112389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/30/2021] [Accepted: 05/12/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction: Point-of-care ultrasound (POCUS) is the most rapidly growing imaging modality for acute care. Despite increased use, there is still wide variability and less evidence regarding its clinical utility for the perioperative setting compared to other acute care settings. This study sought to demonstrate the impact of POCUS examinations for acute hypoxia and hypotension occurring in the post-anesthesia care unit (PACU) versus traditional bedside examinations. Methods: This study was designed as a multi-center prospective observational study. Adult patients who experienced a reduced mean arterial blood pressure (MAP < 60mmHG) and/or a reduced oxygen saturation (SpO2 < 88%) in the PACU from 7AM to 4PM were targeted. POCUS was available or not for patient assessment based on PACU team training. All providers who performed POCUS exams received standardized training on cardiac and pulmonary POCUS. All POCUS exam findings were recorded on a standardized form and the number of suspected mechanisms to trigger the acute event were captured before and after the POCUS exam. PACU length of stay (minutes) across groups was the primary outcome. Results: In total, 128 patients were included in the study, with 92 patients receiving a POCUS exam. Comparison of PACU time between the POCUS group (median = 96.5 min) and no-POCUS groups (median = 120.5 min) demonstrated a reduction for the POCUS group, p = 0.019. Hospital length of stay and 30-day hospital readmission did not show a significant difference between groups. Finally, there was a reduction in the number of suspected diagnoses from before to after the POCUS examination for both pulmonary and cardiac exams, p-values < 0.001. Conclusions: Implementation of POCUS for assessment of acute hypotension and hypoxia in the PACU setting is associated with a reduced PACU length of stay and a reduction in suspected number of diagnoses.
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A Nationwide Analysis of Cleft Palate Repair: Impact of Local Anesthesia on Operative Outcomes and Hospital Cost. Plast Reconstr Surg 2021; 147:978e-989e. [PMID: 34019509 DOI: 10.1097/prs.0000000000007987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This study investigates the associations between local anesthesia practice and perioperative complication, length of stay, and hospital cost for palatoplasty in the United States. METHODS Patients undergoing cleft palate repair between 2004 and 2015 were abstracted from the Pediatric Health Information System database. Perioperative complication, length of stay, and hospital cost were compared by local anesthesia status. Multiple logistic regressions controlled for patient demographics, comorbidities, and hospital characteristics. RESULTS Of 17,888 patients from 49 institutions who met selection criteria, 8631 (48 percent), 4447 (25 percent), and 2149 (12 percent) received epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone, respectively. The use of epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with decreased perioperative complication [adjusted OR, 0.75 (95 percent CI, 0.61 to 0.91) and 0.63 (95 percent CI, 0.47 to 0.83); p = 0.004 and p = 0.001, respectively]. Only bupivacaine- or ropivacaine-alone recipients experienced a significantly reduced risk of prolonged length of stay on adjusted analysis [adjusted OR, 0.71 (95 percent CI, 0.55 to 0.90); p = 0.005]. Risk of increased cost was reduced in users of any local anesthetic (p < 0.001 for all). CONCLUSIONS Epinephrine-containing bupivacaine or bupivacaine or ropivacaine alone was associated with reduced perioperative complication following palatoplasty, while only the latter predicted a decreased postoperative length of stay. Uses of epinephrine-containing lidocaine, epinephrine-containing bupivacaine, and bupivacaine or ropivacaine alone were all associated with decreased hospital costs. Future prospective studies are warranted to further delineate the role of local anesthesia in palatal surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Levy N, Santer P, Zucco L, Nabel S, Korsunsky G, Ramachandran SK. Evaluation of early postoperative intravenous opioid rescue as a novel quality measure in patients who receive thoracic epidural analgesia: a retrospective cohort analysis and prospective performance improvement intervention. BMC Anesthesiol 2021; 21:120. [PMID: 33874890 PMCID: PMC8054410 DOI: 10.1186/s12871-021-01332-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 03/31/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND In this study, we explored the utility of intravenous opioid rescue analgesia in the post anesthesia care unit (PACU-OpResc) as a single marker of thoracic epidural analgesia (TEA) failure and evaluated the resource implications and quality improvement applications of this measure. METHODS We performed a retrospective analysis of all TEA placements over a three-year period at a single academic medical center in Boston, Massachusetts. The study exposure was PACU-OpResc. Primary outcome was PACU length of stay (LOS). Secondary outcomes included reasons for delayed PACU discharge and intraoperative hypotension. The analyses were adjusted for confounding variables including patient comorbidities, surgical complexity, intraoperative intravenous opioids, chronic opioid use and local anesthetic bolus through TEA catheter. Post analysis chart review was conducted to determine the positive predictive value (PPV) of PACU-OpResc for inadequate TEA. As a first Plan-Do-Study-Act cycle, we then introduced a checkbox for documentation of a sensory level check after TEA placement. Post implementation data was collected for 7 months. RESULTS PACU-OpResc was required by 211 (22.1%) patients who received preoperative TEA, was associated with longer PACU LOS (incidence rate ratio 1.20, 95% CI:1.07-1.34, p = 0.001) and delayed discharge due to inadequate pain control (odds ratio 5.15, 95% CI 3.51-7.57, p < 0.001). PACU-OpResc had a PPV of 76.3 and 60.4% for re-evaluation and manipulation of the TEA catheter in PACU, respectively. Following implementation of a checkbox, average monthly compliance with documented sensory level check after TEA placement was noted to be 39.7%. During this time, a reduction of 8.2% in the rate of PACU-OpResc was observed. CONCLUSIONS This study demonstrates that PACU-OpResc can be used as a quality assurance measure or surrogate for TEA efficacy, to track performance and monitor innovation efforts aimed at improving analgesia, such as our intervention to facilitate sensory level checks and reduced PACU-OpResc. TRIAL REGISTRATION not applicable.
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Affiliation(s)
- Nadav Levy
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA.
| | - Peter Santer
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Liana Zucco
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Sarah Nabel
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Galina Korsunsky
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, USA
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Ritz ML, Rosenfeld DM, Spangehl M, Misra L, Khurmi N, Butterfield RJ, Buras MR, Gorlin AW. Evaluation of the use of spinal anesthesia administered prior to proceeding to the operating room in patients undergoing total joint arthroplasty. ACTA ACUST UNITED AC 2021. [DOI: 10.1016/j.pcorm.2020.100154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zierau M, Li D, Lapointe AP, Ip KI, McKinney AM, Thompson A, Puglia MP, Vlisides PE. Cortical Oscillations and Connectivity During Postoperative Recovery. J Neurosurg Anesthesiol 2021; 33:87-91. [PMID: 31436606 PMCID: PMC7031022 DOI: 10.1097/ana.0000000000000636] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to test whether postoperative electroencephalographic (EEG) biomarkers, parietal alpha power and frontal-parietal connectivity, were associated with measures of clinical recovery in adult surgical patients. METHODS This is a secondary analysis of a prospective cohort study that analyzed intraoperative connectivity patterns in adult surgical patients (N=53). Wireless, whole-scalp EEG data were collected in the postanesthesia care unit and assessed for relevance to clinical and neurocognitive recovery. Parietal alpha power and frontal-parietal connectivity (estimated by weighted phase lag index) were tested for associations with postanesthesia care unit discharge readiness and University of Michigan Sedation Scale scores upon postoperative admission. Bivariable correlation and regression models were constructed to test for unadjusted associations, then multivariable regression models were constructed to adjust for confounding. RESULTS Postoperative EEG patterns were characterized by a predominance of alpha parietal power and frontal-parietal connectivity. Neither relative parietal alpha power (% alpha, -0.25; 95% confidence interval [CI], -1.41 to 0.90; P=0.657) nor alpha frontal-parietal connectivity (weighted phase lag index, -82; 95% CI, -237 to 73; P=0.287) were associated with time until postanesthesia discharge criteria were met. Furthermore, neither alpha power (-0.03; 95% CI, -0.07 to 0.01; P=0.206) nor alpha frontal-parietal connectivity (-4.2; 95% CI, -11 to 2.6; P=0.226) were associated with sedation scores upon initial assessment. CONCLUSIONS In a pragmatic study investigating clinically relevant endpoints of postoperative recovery, we found no correlation with surrogate measures of brain neurodynamics. These data contribute to the overall impetus of developing anesthetic-invariant and generalizable markers of brain recovery.
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Affiliation(s)
| | - Duan Li
- Department of Anesthesiology
- Center for Consciousness Science
| | - Andrew P Lapointe
- Department of Radiology, University of Calgary Cummings School of Medicine, Calgary, AB, Canada
| | - Ka I Ip
- Department of Psychology, University of Michigan, Ann Arbor, MI
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Mann GE, Flamer SZ, Nair S, Maher JN, Cowan B, Streiff A, Adams D, Shaparin N. Opioid-free anesthesia for adenotonsillectomy in children. Int J Pediatr Otorhinolaryngol 2021; 140:110501. [PMID: 33290925 DOI: 10.1016/j.ijporl.2020.110501] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/21/2020] [Accepted: 11/12/2020] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Opioids are administered during the intraoperative and postoperative periods in pediatric adenotonsillectomy and tonsillectomy. Non-opioid analgesics are often used as an analgesic during pediatric adenotonsillectomy and tonsillectomy. In this hypothesis generating study, we are evaluating safety and efficacy of stand-alone opioid analgesia for adenotonsillectomy and tonsillectomy. METHODS This is a single-center retrospective chart review of patients ages 2 to 13 who underwent elective adenotonsillectomy and tonsillectomy. We used a convenience sampling method to select patients who received intraoperative intravenous fentanyl, acetaminophen, ibuprofen, or any combination thereof. The following outcomes were analyzed in this study: (i) the length of Post Anesthesia Care Unit stay, (ii) administration of postoperative opioids; (iii) postoperative opioid equivalents required; (iv) administration of postoperative non-opioid analgesics; and (v) inpatient admission from ED within 30 days. We used univariate analysis to compare the data points. RESULTS We analyzed data from 323 patients who underwent adenotonsillectomy and tonsillectomy. The Post Anesthesia Care Unit length stay was similar for the intraoperative opioid-free and intraoperative opioid groups, 146.68 (±67.35) and 143.18 (±37.85) minutes, respectively (p = 0.586). Additionally, 102 patients (73.4%) in the intraoperative opioid-free group and 184 patients (83.2%) in the intraoperative opioid group did not receive any postoperative opioids (p = 0.033). The incidence of adverse events was similar between the intraoperative opioid-free and intraoperative opioid groups 3 (2.2%) and 5 (2.7%) respectively, p-value 0.749. A subgroup analysis comparing extracapsular 235 (72.8%) versus intracapsular 88 (27.2%) tonsillectomy yielded similar results. CONCLUSION In this study, our data indicates that American Society of Anesthesiologists I- II pediatric patients undergoing adenotonsillectomy and tonsillectomy can be efficiently and safely managed with an opioid-free intraoperative and postoperative analgesic regimen. Due to the explained limitations, our study results should be interpreted cautiously.
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Affiliation(s)
- Glenn E Mann
- Albert Einstein College of Medicine, Bronx, USA; Montefiore Medical Center, Department of Anesthesiology, USA.
| | | | - Singh Nair
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - James N Maher
- Icahn School of Medicine at Mount Sinai, Department of Anesthesiology, Perioperative and Pain Medicine, USA
| | - Brandon Cowan
- Oakland University William Beaumont School of Medicine, USA
| | - Agathe Streiff
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - David Adams
- Montefiore Medical Center, Department of Anesthesiology, USA
| | - Naum Shaparin
- Albert Einstein College of Medicine, Bronx, USA; Montefiore Medical Center, Department of Anesthesiology, USA
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Desai N, Chan E, El-Boghdadly K, Albrecht E. Caudal analgesia versus abdominal wall blocks for pediatric genitourinary surgery: systematic review and meta-analysis. Reg Anesth Pain Med 2020; 45:924-933. [DOI: 10.1136/rapm-2020-101726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/08/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023]
Abstract
BackgroundCaudal block is a well-established technique for providing perioperative analgesia in pediatric genitourinary surgery, but abdominal wall blocks such as ilioinguinal–iliohypogastric (II-IH) and transversus abdominis plane (TAP) block are increasingly being used.MethodsOur protocol for this meta-analysis was registered on PROSPERO (CRD42020163497). Central, CINAHL, Embase, Global Health, LILACS, MEDLINE, Scopus and Web of Science were searched from inception to 11 December 2019 for randomized controlled trials that included pediatric patients having genitourinary surgery with II-IH or TAP block as the intervention and caudal analgesia as the comparator. For continuous and dichotomous outcomes, respectively, we calculated the mean difference using the inverse-variance method and the risk ratio with the Mantel-Haenzel method.ResultsIn all, 23 trials with 1399 patients were included. II-IH and TAP block were similar to caudal analgesia in the coprimary outcomes of the postoperative pain score at 0–2 hours (high-quality evidence) and the need for in-hospital rescue analgesia (moderate-quality evidence consequent to downgrading by publication bias). No subgroup differences in regard to the type of abdominal wall block or the method of block localization were demonstrated for these primary outcomes. Relative to caudal analgesia, II-IH and TAP block reduced the incidence of postoperative motor blockade and the time to micturition.ConclusionsThis meta-analysis was limited by unclear risk of selection and performance biases and significant heterogeneity. In summary, II-IH and TAP block are a non-invasive and reasonable alternative to caudal analgesia in pediatric genitourinary surgery.
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Qureshi F, Meena SC, Kumar V, Jain K, Chauhan R, Luthra A. Influence of Epidural Ropivacaine with or without Dexmedetomidine on Postoperative Analgesia and Patient Satisfaction after Thoraco-Lumbar Spine Instrumentation: A Randomized, Comparative, and Double-Blind Study. Asian Spine J 2020; 15:324-332. [PMID: 32872755 PMCID: PMC8217855 DOI: 10.31616/asj.2020.0072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/20/2020] [Indexed: 01/09/2023] Open
Abstract
Study Design This was a prospective, randomized, and double-blind study. Purpose Thoraco-lumbar spine surgery is associated with severe postoperative pain and can cause chronic pain. We aimed to compare the impact of epidural ropivacaine with and without dexmedetomidine on postoperative analgesia after thoracolumbar spine instrumentation wherein an epidural catheter was placed by the surgeon intraoperatively. Overview of Literature Very few studies have reported the use of epidural dexmedetomidine in spine surgeries. When used via the epidural route, dexmedetomidine is safe and efficacious and is associated with reduced rescue analgesia consumption, increased duration of analgesia, reduced pain scores, but not with major hemodynamic adverse effects. Methods Total 60 American Society of Anesthesiologists I–III adult patients aged 18–65 years who were scheduled to undergo thoraco-lumbar spine instrumentation were randomly allocated into group RD (epidural ropivacaine+dexmedetomidine) or group R (epidural ropivacaine plus saline). We aimed to compare the total rescue analgesic consumption on postoperative day 0, 1, and 2. Moreover, we studied the time to first rescue analgesia with visual analogue scale score <4 and the overall patient satisfaction scores. Results There was no difference between the demographic characteristics of the two groups. The mean value of total rescue analgesia consumption was 162.5±68.4 mg in the RD group and 247.5±48.8 mg in the R group. The mean time to first rescue analgesia was 594.6±83.0 minutes in the RD group and 103.6±53.2 minutes in the R group. The mean patient satisfaction score was 4.2±0.7 in the RD group and 3.2±0.6 in the R group. No patient had any respiratory depression or prolonged motor blockade during the postoperative period. Conclusions This study demonstrated the superior efficacy, in terms of postoperative analgesia and patient satisfaction scores, of epidural ropivacaine plus dexmedetomidine over that of ropivacaine alone in patients undergoing surgery for thoraco-lumbar spine.
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Affiliation(s)
- Faisal Qureshi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shyam Charan Meena
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Kumar
- Department of Orthopaedic surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kajal Jain
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Schulz EB, Phillips F, Waterbright S. Case-mix adjusted postanaesthesia care unit length of stay and business intelligence dashboards for feedback to anaesthetists. Br J Anaesth 2020; 125:1079-1087. [PMID: 32863015 DOI: 10.1016/j.bja.2020.06.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 06/04/2020] [Accepted: 06/22/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Despite advances in business intelligence software and evidence that feedback to doctors can improve outcomes, objective feedback regarding patient outcomes for individual anaesthetists is hampered by lack of useful benchmarks. We aimed to address this issue by producing case-mix and risk-adjusted postanaesthesia care unit (PACU) length of stay (LOS) benchmarks for integration into modern reporting tools. METHODS We extended existing hospital information systems to calculate predicted PACU LOS using a neural network trained on patient age, surgery duration, sex, operating specialty, urgency, weekday, and insurance status (n=100 511). We then calculated the difference between observed mean and predicted PACU LOS for individual doctors, and compared the results with and without case-mix adjustment. We report practical implications of using visual analytics dashboards displaying the difference between observed and predicted PACU LOS to provide feedback to anaesthetic doctors. RESULTS The neural network accounted for over half of observed variation in individual doctors' mean PACU LOS (mean predicted and mean actual LOS Spearman's r2=0.57). Account for case-mix reduced apparent spread, with 80% of individual doctors falling in a band of 4.3 min after case-mix adjusting, compared with a range of 24 min without adjustment. Case-mix adjusting also identified different individual doctors as outliers (Weighted Cohen's kappa [κ]=0.27). Finally, we demonstrated that we were able to integrate the adjusted metrics into routine reporting tools. CONCLUSION With caution, case-mix adjustment of anaesthetic outcome measures such as PACU LOS potentially provides a useful continuous quality improvement tool. Unadjusted outcome measures are imprecise at best and misleading at worst.
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Affiliation(s)
- Erich B Schulz
- Department of Anaesthesia, Mater Health, Brisbane, Australia.
| | - Frank Phillips
- Department of Anaesthesia, Mater Health, Brisbane, Australia; Mater Clinical Unit, University of Queensland School of Medicine, Brisbane, Australia
| | - Siall Waterbright
- College of Arts and Social Sciences, Australian National University, Canberra, Australia
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Liu S, Wang Z, Xiong J, Wan L, Luo A, Wang X. Continuous Analysis of Critical Incidents for 92,136 Postanesthesia Care Unit Patients of a Chinese University Hospital. J Perianesth Nurs 2020; 35:630-634. [PMID: 32778494 DOI: 10.1016/j.jopan.2020.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 02/22/2020] [Accepted: 03/02/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To determine the spectrum of critical incidents in postanesthesia care unit (PACU) and the possible prediction and prevention of the worse scenario-associated critical incidents. DESIGN A retrospective observational study. METHODS The critical incidents in PACU comprising 92,136 patients were recorded. The incidents included the following disorders: delayed recovery, pain, bleeding, hypothermia, unplanned transfer to intensive care unit, shivering, agitation, nausea and vomiting, and respiratory or cardiovascular-related critical incidents. We then performed descriptive analyses and t test or χ2 test on the collected data. FINDINGS A total of 1,760 critical incidents were recorded in 1,417 patients among 92,136 patients. Most critical incidents were associated with the patients after general anesthesia and general or gynecologic surgery. The most common critical incidents noted in the present study were pain, followed by cardiovascular-related and respiratory-related incidents. The average length of stay in PACU was 61.50 ± 44.40 minutes for the patients with critical incidents and 28.50 ± 19.40 minutes for the patients without critical incidents. CONCLUSIONS Critical incidents lead to longer length of stay in the PACU. Regular inspection and immediate response for critical incidents in the PACU is essential for the maintenance of the quality of the immediate postoperative care.
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Affiliation(s)
- Shangkun Liu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhenxing Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Juan Xiong
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Li Wan
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xueren Wang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China.
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Laporta ML, O'Brien EK, Stokken JK, Choby G, Sprung J, Weingarten TN. Anesthesia Management and Postanesthetic Recovery Following Endoscopic Sinus Surgery. Laryngoscope 2020; 131:E815-E820. [PMID: 32652629 DOI: 10.1002/lary.28862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Delayed anesthesia recovery following endoscopic sinus surgery (ESS) can be an indicator of immediate complications and negatively impact healthcare efficiency. This study aims to examine clinical factors with a focus on improving clinical practice. METHODS Medical records of patients undergoing ESS under general anesthesia from 2014 to 2018 were reviewed. Based on the interquartile range of anesthesia recovery for the cohort, patients in the upper quartile were categorized as "prolonged" and the lowest three quartiles as "goal" recovery. Patient and surgical characteristics were investigated. RESULTS Analyzing 416 patients who underwent ESS, the median anesthesia recovery time was 48 [35-66] minutes. Prolonged recovery was associated with higher body mass index (odds ratio 1.50 [95% confidence interval 1.03-2.18] per 10 kg/m2 , P = .03) and surgical duration (1.37 [1.10-1.72] per hour, P < .01). Inversely, goal recovery was associated with preoperative acetaminophen (0.61 [0.38-0.98], P = .04) and intraoperative remifentanil (0.55 [0.32-0.93], P = .03). Patients with prolonged recovery had higher rates of severe pain (33 (31.7%) vs. 25 (8.0%), P < .01), respiratory depression (7 [6.7] vs. 2 [0.6], P < .01), oversedation (39 [37.5] vs. 39 [12.5], P < .01), and the need for rescue opioids (52 [50] vs. 71 [22.8], P < .01). In addition to reduced postanesthesia recovery time, patients who were administered preemptive acetaminophen had lower rates of severe pain (OR 0.55 [0.31-0.98], P = .04) and nausea and vomiting (0.39 [0.17-0.87], P = .02). CONCLUSION Our findings substantiate the use of acetaminophen and remifentanil in ESS, facilitating anesthesia recovery. Broadly consideration of preemptive acetaminophen could further increase postoperative comfort in ESS. LEVEL OF EVIDENCE 4 - Retrospective. Laryngoscope, 131:E815-E820, 2021.
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Affiliation(s)
- Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Erin K O'Brien
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Janalee K Stokken
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Garret Choby
- Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Kim SY, Avila J, Lee J, Lee T, Macres S, Applegate RL, Wilson MD, Zhou J. Impact of preoperative pectoralis plane nerve blocks for mastectomy on perioperative opioid consumption: a retrospective study. Pain Manag 2020; 10:159-165. [PMID: 32342719 DOI: 10.2217/pmt-2019-0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To compare perioperative opioid consumption for patients undergoing mastectomy surgery with or without pectoralis nerve (PECS) plane blocks. Patients & methods: Retrospective study evaluating 152 adult females with mastectomies. Demographics, postanesthesia care unit stay duration and opioid consumption data at three time points were collected and analyzed for statistical significance. Results: 98 patients were included in the PECS block group, 54 patients were in the general anesthesia only group. Age and BMI were comparable. Total perioperative intravenous opioid consumption was less in the PECS block group (50.88 mg) compared with the general anesthesia only group (67.83 mg), p < 0.001. Conclusion: Acute pain after mastectomy is often severe. PECS plane block may decrease perioperative opioid consumption after mastectomy surgery compared with general anesthesia alone.
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Affiliation(s)
- Susan Y Kim
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Jorge Avila
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Joshua Lee
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Tim Lee
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Stephen Macres
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Richard L Applegate
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Machelle D Wilson
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
| | - Jon Zhou
- Department of Anesthesiology & Pain Medicine, University of California, Davis Medical Center, Sacramento, CA 95817, USA.,Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, CA 95616, USA
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Rosenbaum AJ, Moore KJ, Louie M, Schiff LD, Carey ET. Postanesthesia Care Unit Stay and Complications After Same-Day Discharge Laparoscopic Hysterectomy. J Gynecol Surg 2020. [DOI: 10.1089/gyn.2019.0099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Alan J. Rosenbaum
- Division of Global Women's Health, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kristin J. Moore
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Michelle Louie
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lauren D. Schiff
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erin T. Carey
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Effect of subarachnoid anesthesia combined with propofol target-controlled infusion on blood loss and transfusion for posterior total hip arthroplasty in elderly patients. Chin Med J (Engl) 2020:650-656. [PMID: 32197030 PMCID: PMC7190232 DOI: 10.1097/cm9.0000000000000688] [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] [Indexed: 11/25/2022] Open
Abstract
Supplemental Digital Content is available in the text Background Intravertebral and general anesthesia (GA) are two main anesthesia approaches but both have defects. This study was aimed to evaluate the effect of subarachnoid anesthesia combined with propofol target-controlled infusion (TCI) on blood loss and transfusion for total hip arthroplasty (THA) in elderly patients in comparison with combined spinal-epidural anesthesia (CSEA) or GA. Methods Totally, 240 patients (aged ≥65 years, American Society of Anesthesiologists [ASA] I–III) scheduled for posterior THA were enrolled from September 1st, 2017 to March 1st, 2018. All cases were randomly divided into three groups to receive CSEA (group C, n = 80), GA (group G, n = 80), or subarachnoid anesthesia and propofol TCI (group T, n = 80), respectively. Primary outcomes measured were intra-operative blood loss, autologous and allogeneic blood transfusion, mean arterial pressure at different time points, length of stay in post-anesthesia care unit (PACU), length of hospital stay, and patient satisfaction degree. Furthermore, post-operative pain scores and complications were also observed. The difference of quantitative index between groups were analyzed by one-way analysis of variance, repeated measurement generalized linear model, Student-Newman-Keuls test or rank-sum test, while ratio index was analyzed by Chi-square test or Fisher exact test. Results Basic characteristics were comparable among the three groups. Intra-operative blood loss in group T (331.53 ± 64.33 mL) and group G (308.03 ± 64.90 mL) were significantly less than group C (455.40 ± 120.48 mL, F = 65.80, P < 0.001). Similarly, the autologous transfusion of group T (130.99 ± 30.36 mL) and group G (124.09 ± 24.34 mL) were also markedly less than group C (178.31 ± 48.68 mL, F = 52.99, P < 0.001). The allogenetic blood transfusion of group C (0 [0, 100.00]) was also significantly larger than group T (0) and group G (0) (Z = 2.47, P = 0.047). Except for the baseline, there were significant differences in mean arterial blood pressures before operation (F = 496.84, P < 0.001), 10-min after the beginning of operation (F = 351.43, P < 0.001), 30-min after the beginning of operation (F = 559.89, P < 0.001), 50-min after the beginning of operation (F = 374.74, P < 0.001), and at the end of operation (F = 26.14, P < 0.001) among the three groups. Length of stay in PACU of group T (9.41 ± 1.19 min) was comparable with group C (8.83 ± 1.26 min), and both were significantly shorter than group G (16.55 ± 3.10 min, F = 352.50, P < 0.001). There were no significant differences among the three groups in terms of length of hospitalization and post-operative visual analog scale scores. Patient satisfaction degree of group T (77/80) was significantly higher than group C (66/80, χ2 = 7.96, P = 0.004) and G (69/80, χ2 = 5.01, P = 0.025). One patient complained of post-dural puncture headache and two complained of low back pain in group C, while none in group T. Incidence of post-operative nausea and vomiting in group G (10/80) was significantly higher than group T (3/80, χ2 = 4.10, P = 0.043) and group C (2/80, χ2 = 5.76, P = 0.016). No deep vein thrombosis or delayed post-operative functional exercise was detected. Conclusions Single subarachnoid anesthesia combined with propofol TCI seems to perform better than CSEA and GA for posterior THA in elderly patients, with less blood loss and peri-operative transfusion, higher patient satisfaction degree and fewer complications. Trial registration chictr.org.cn: ChiCTR-IPR-17013461; http://www.chictr.org.cn/showproj.aspx?proj=23024.
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Weissman C, Scemama J, Weiss YG. The ratio of PACU length-of-stay to surgical duration: Practical observations. Acta Anaesthesiol Scand 2019; 63:1143-1151. [PMID: 31264209 DOI: 10.1111/aas.13421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 04/29/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Operating room (OR) and post-anesthesia care unit (PACU) activity are closely linked since the number, type, and sequence of surgeries influence subsequent PACU activity. We aimed to explore the relationship between duration-of-surgery (DOS) and PACU length-of-stay (LOS), the PACU-LOS:DOS ratio, since it is among the determinants of the number of PACU beds and nurse staffing required to insure efficient egress of patients from the OR. METHODS PACU-LOS:DOS ratio was examined using retrospective data from a tertiary medical center's surgical information system (Phase 1) and prospectively collected data from a convenience sample of post-operative patients (Phase 2). RESULTS Phase 1 included 17 047 patients, the majority (73%) with PACU-LOS:DOS ratios >1.0, indicating PACU-LOS longer than DOS. Median PACU-LOS was 117 minutes, median DOS was 80 minutes, and median PACU-LOS/DOS ratio was 1.5. PACU-LOS showed greater variability than DOS because of extended PACU stays. Phase 2 (n = 2054) confirmed Phase 1 results (median PACU-LOS/DOS ratio - 1.8). In both phases at a DOS of >130 minutes PACU-LOS/DOS ratio became <1.0. In 24% of Phase 2 patients PACU-LOS was prolonged because of administrative issues. Post-operative, more than pre- and intra-operative, measurements influenced PACU-LOS. CONCLUSIONS The PACU-LOS/DOS ratio proved useful for demonstrating interactions between 2 central components of the surgical system. The many patients with PACU-LOS:DOS ratios >1.0 provides objective evidence for the number of PACU beds exceeding the number of ORs.
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Affiliation(s)
- Charles Weissman
- Department of Anesthesiology and Critical Care Medicine and Hospital Administration Hadassah – Hebrew University Medical Center Jerusalem Israel
- Hebrew University – Hadassah School of Medicine Jerusalem Israel
| | - Jeremy Scemama
- Department of Anesthesiology and Critical Care Medicine and Hospital Administration Hadassah – Hebrew University Medical Center Jerusalem Israel
- Hebrew University – Hadassah School of Medicine Jerusalem Israel
| | - Yoram G. Weiss
- Department of Anesthesiology and Critical Care Medicine and Hospital Administration Hadassah – Hebrew University Medical Center Jerusalem Israel
- Hebrew University – Hadassah School of Medicine Jerusalem Israel
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Tabrizi S, Malhotra V, Turnbull ZA, Goode V. Implementation of Postoperative Nausea and Vomiting Guidelines for Female Adult Patients Undergoing Anesthesia During Gynecologic and Breast Surgery in an Ambulatory Setting. J Perianesth Nurs 2019; 34:851-860. [DOI: 10.1016/j.jopan.2018.10.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/25/2018] [Accepted: 10/27/2018] [Indexed: 10/27/2022]
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Rungwattanakit P, Sondtiruk T, Nimmannit A, Sirivanasandha B. Perioperative Factors Associated with Severe Pain in Post-Anesthesia Care Unit after Thoracolumbar Spine Surgery: A Retrospective Case-Control Study. Asian Spine J 2019; 13:441-449. [PMID: 30685952 PMCID: PMC6547386 DOI: 10.31616/asj.2018.0121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 10/18/2018] [Indexed: 11/23/2022] Open
Abstract
Study Design A retrospective case-control study. Purpose To evaluate the effect of nitrous oxide and anesthetic and operative factors associated with severe pain in the early postoperative period after thoracolumbar spine surgery. Overview of Literature Thoracolumbar spine surgery is the most common procedure in spine surgery, and up to 50% of the patients suffer from moderate to severe pain. Nitrous oxide has analgesic, anxiolytic, and anesthetic effects; nevertheless, its benefits for early postoperative pain control and opioid consumption remain to be established. Methods The medical records of eligible participants who underwent thoracolumbar spine surgery between July 2016 and February 2017 were reviewed. Enrolment was performed consecutively until reaching 90 patients for the case (severe pain) group (patients with a pain score of >7 out of 10 at least once during the post-anesthesia care unit [PACU] admission), and 90 patients for the control (mild-to-moderate pain) group (patients with a pain score of <7 in every PACU assessment). The data collected comprised patient factors, anesthetic factors, surgical factors, PACU pain score, and PACU pain management. Results A total of 197 patients underwent thoracolumbar spine surgery with an incidence of early postoperative severe pain of 53.3%. The case-control study revealed no differences in the factors related to pain intensity. A subgroup analysis was performed for failed back surgery syndrome (FBSS), spinal stenosis, and spondylolisthesis. After multivariate analyses, only the age group of 19–65 years and the baseline Oswestry Disability Index (ODI) were found to be significant risk factors for early postoperative severe pain in the PACU (odds ratio [OR], 2.86; 95% confidence interval [CI], 1.32–6.25; OR, 1.03; 95% CI, 1.01–1.05, respectively). Conclusions Nitrous oxide, anesthetic agents, and surgical techniques did not affect the early postoperative pain severity. Age under 66 years and the baseline ODI were the significant risk factors for pain intensity during the early postoperative period of the FBSS, spinal stenosis, and spondylolisthesis subgroups.
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Affiliation(s)
- Paweenus Rungwattanakit
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tarnkamon Sondtiruk
- Department of Nursing, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Akarin Nimmannit
- Department of Research, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Busara Sirivanasandha
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Rosenfeld DM, Knapp KE, Spiro JA, Gorlin AW, Ramakrishna H, Trentman TL. The effect of ampule size of fentanyl on perioperative intravenous opioid dosing. J Anaesthesiol Clin Pharmacol 2018; 34:513-517. [PMID: 30774233 PMCID: PMC6360893 DOI: 10.4103/joacp.joacp_17_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND AIMS There are limited data on the effect of ampule size on drug dosing. The objective of this study is to determine the effect of ampule size on perioperative opioid dosing and post-anesthesia care unit (PACU) outcomes. MATERIAL AND METHODS This was a retrospective review of patients undergoing robotically assisted laparoscopic radical prostatectomy before and after a 5-ml fentanyl ampule was discontinued. The primary outcome was intraoperative opioid administration divided into fentanyl at induction of anesthesia, total fentanyl, and total opioid. Secondary outcomes observed in PACU included the opioid administered, visual analog scale (VAS) pain scores, postoperative nausea and vomiting, and length of stay in PACU. RESULTS A total of 100 patients (50 PRE and 50 POST) were included. In the intraoperative opioid administration, mean (SD) of fentanyl at induction was 117.0 (49.3) in PRE group and 85.0 (35.4) μg in POST group (P < 0.01). The total fentanyl requirement was 247.0 (31.0) in PRE group and 158.5 (85.1) μg in POST group (P < 0.01). The total opioid in intravenous morphine equivalents (IVME) was 34.1 (5.8) in PRE group and 23.2 (6.8) mg in POST group (P < 0.01). Among the secondary outcomes, mean (SD) of IVME of opioid was 7.7 (8.2) in PRE group and 9.9 (8.1) mg in POST group (P = 0.18). The VAS pain score on arrival was 0.7 (1.4) in PRE group and 3.8 (3.3) in POST group (P < 0.01). The cumulative VAS pain score was 2.3 (2.0) in PRE group and 3.3 (2.2) in POST group (P < 0.01). The length of stay was significantly more in POST group, 193.8 (75.8) minutes, as compared with PRE group, 138.6 (61.0) minutes (P < 0.01). CONCLUSIONS A change in the ampule size significantly affected intraoperative dosing, PACU pain scores, and PACU length of stay in patients undergoing robotically assisted laparoscopic radical prostatectomy under general anesthesia. This was explained by clinician's desire to conserve the drug and avoid the complex process of narcotic waste disposal.
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Affiliation(s)
- David M. Rosenfeld
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Kathleen E. Knapp
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Joshua A. Spiro
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Andrew W. Gorlin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Harish Ramakrishna
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Terrence L. Trentman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Preoperative Risk Assessment to Guide Prophylaxis and Reduce the Incidence of Postoperative Nausea and Vomiting. J Perianesth Nurs 2018; 34:74-85. [PMID: 29945846 DOI: 10.1016/j.jopan.2018.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/31/2018] [Accepted: 02/03/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE This article describes the implementation of a postoperative nausea and vomiting (PONV) risk prediction and prophylaxis protocol. DESIGN This is a retrospective pre/post implementation quality improvement project. METHODS This project used chart reviews to assess the impact of the implemented PONV assessment and prophylaxis in a sample population of adult females undergoing gynecologic surgical procedures. FINDINGS The mean number of prophylactic antiemetics administered significantly increased during the postimplementation period from 3.64 (SD, 0.878) in the preimplementation period to 4.07 (SD, 1.021) in the postimplementation period (P < .001). The greatest increase in antiemetic administration occurred in the moderate-risk (risk score, 4) and the high-risk (risk score, 5 to 6) groups. The incidence of PONV decreased from 32.3% in the preimplementation period to 28.9% in the postimplementation period; however, this reduction did not meet statistical significance. Antiemetic administration compliance increased from 37% in the preimplementation group to 61% in the postimplementation group (P < .001). CONCLUSIONS The results of this project suggest that a risk-tailored approach to PONV prophylaxis using a risk assessment tool along with treatment recommendations is effective at reducing the incidence of PONV. The effectiveness of this approach is limited by the involvement of the anesthesia providers responsible for completing the assessments and administering PONV prophylaxis.
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Kaye AD, Helander EM, Vadivelu N, Lumermann L, Suchy T, Rose M, Urman RD. Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions. Pain Ther 2017; 6:129-141. [PMID: 28853044 PMCID: PMC5693810 DOI: 10.1007/s40122-017-0079-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Indexed: 02/02/2023] Open
Abstract
The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician's role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs.
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Affiliation(s)
- Alan D Kaye
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA
| | - Erik M Helander
- Department of Anesthesiology, Louisiana State University, New Orleans, LA, USA
| | - Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Leandro Lumermann
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Thomas Suchy
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Margaret Rose
- Department of Anesthesiology, Yale University School of Medicine, New Heaven, CT, USA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Institute for Safety in Office-Based Surgery, Boston, MA, USA.
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Chan JJI, Thong SY, Tan MGE. Factors affecting postoperative pain and delay in discharge from the post-anaesthesia care unit: A descriptive correlational study. PROCEEDINGS OF SINGAPORE HEALTHCARE 2017. [DOI: 10.1177/2010105817738794] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Pain occurring in the post-anaesthesia care unit (PACU) is common, distressing to patients and remains a management challenge for staff. This study aims to identify the factors affecting pain severity and delay in discharge of patients from the PACU. Methods: Data from 590 consecutive postoperative patients in the PACU was collected over one month in 2012 at the Singapore General Hospital. Patient demographics, surgical, intraoperative anaesthetic and recovery data were collected. The primary outcome measured was postoperative pain score and secondary outcome was a delay in discharge. Univariate and multivariate logistic regression were performed to determine preoperative and intraoperative variables that may be associated with pain and delayed discharge. Results: The majority (67.6%) of patients reported no to mild pain while 32.3% reported moderate to severe pain; 65.4% of patients had delayed discharge and 28.3% of these were a result of uncontrolled pain. Factors associated with moderate to severe postoperative pain included younger age, same day admissions, duration of operation >2 h, abdominal, upper limb and spine surgeries and use of general anaesthesia. Factors associated with delay in discharge included higher body mass index, abdominal, spine and superficial surgeries, use of general anaesthesia, moderate to severe pain score and use of nurse controlled analgesia. Conclusions: This study identifies predictive factors for postoperative pain and delay in discharge from the PACU. Knowledge of these factors may help in better clinical judgment for postoperative pain management and can lead to quality improvement measures for patient management and work flow in the PACU.
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Affiliation(s)
- Jason Ju In Chan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Sze Ying Thong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Michelle Geoh Ean Tan
- Pain Management Centre and Department of Anaesthesiology, Singapore General Hospital, Singapore
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Meert AP, Grigoriu B, Licker M, Van Schil PE, Berghmans T. Intensive care in thoracic oncology. Eur Respir J 2017; 49:49/5/1602189. [DOI: 10.1183/13993003.02189-2016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/06/2017] [Indexed: 01/21/2023]
Abstract
The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.
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Infrared pupillometry helps to detect and predict delirium in the post-anesthesia care unit. J Clin Monit Comput 2017; 32:359-368. [PMID: 28275978 DOI: 10.1007/s10877-017-0009-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 02/25/2017] [Indexed: 01/29/2023]
Abstract
This study evaluates the capability of pupillary parameters to detect and predict delirium in the post-anesthesia care unit (PACU-D) following general anesthesia. PACU-D may complicate and prolong the patient's postoperative course, consequently increasing hospital costs. After institutional approval, 47 patients undergoing surgical interventions with general anesthesia were included in the study. We measured the pupillary reflexes at signing of informed consent, during surgery 20 min after intubation and when the primary inhaled anesthetic was turned off, and 15 and 45 min after PACU admittance and upon discharge from the PACU. We evaluated patients for delirium using the confusion assessment method for the intensive care unit (CAM-ICU) score after 15 and 60 min in the PACU. We chose receiver operating curve (ROC) and area under the curve (AUC) to compare the performance of non-pupillary parameters to pupillary parameters, such as pupil diameter, percent constriction, and dilation velocity, to detect and predict PACU-D. Percent constriction (AUC = 0.93, optimal threshold = 18.5%) and dilation velocity (AUC = 0.93, optimal threshold = 0.35 mm/s) showed excellent ability to detect and predict delirium persisting throughout the PACU stay. These pupillary measures showed superior performance compared to other pupillary measures and features commonly associated with delirium, e.g., age (AUC = 0.73), total opioids (AUC = 0.56), or length of surgery (AUC = 0.40). Our results suggest that pupillometry and the parameters derived from the recording may identify delirious patients in the PACU. This information can help to efficiently structure their care in a timely manner, and potentially avoid adverse complications for the patient and financial consequences for the hospital.
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Shah AC, Nair BG, Spiekerman CF, Bollag LA. Continuous intraoperative epidural infusions affect recovery room length of stay and analgesic requirements: a single-center observational study. J Anesth 2017; 31:494-501. [PMID: 28185011 DOI: 10.1007/s00540-017-2316-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/29/2017] [Indexed: 12/21/2022]
Abstract
PURPOSE Continuous intraoperative epidural analgesia may improve post-operative pain control and decrease opioid requirements. We investigate the effect of epidural infusion initiation before or after arrival in the post-anesthesia care unit on recovery room duration and post-operative opioid use. METHODS We performed a retrospective chart review of abdominal, thoracic and orthopedic surgeries where an epidural catheter was placed prior to surgery at the University of Washington Medical Center during a 24 month period. RESULTS Patients whose epidural infusions were started prior to PACU arrival (Group 2: n = 540) exhibited a shorter PACU length of stay (p = .004) and were less likely to receive intravenous opioids in the recovery room (34 vs. 48%; p < .001) compared to patients whose infusions were started after surgery (Group 1: n = 374). Although the highest patient-reported pain scores were lower in Group 2 (5.3 vs. 6.0; p = .030), no differences in the pain scores prior to PACU discharge were observed. CONCLUSION Intraoperative continuous epidural infusions decrease PACU LOS as discharge criteria for patient-reported NRS pain scores are met earlier.
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Affiliation(s)
- Aalap C Shah
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA. .,Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA, 90048, USA.
| | - Bala G Nair
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Charles F Spiekerman
- Institute for Translational Health Sciences (ITHS), University of Washington, Seattle, WA, USA
| | - Laurent A Bollag
- Department of Anesthesiology and Pain Medicine, University of Washington Medical Center, Seattle, WA, USA
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Preemptive Analgesia in Hip Arthroscopy: A Randomized Controlled Trial of Preemptive Periacetabular or Intra-articular Bupivacaine in Addition to Postoperative Intra-articular Bupivacaine. Arthroscopy 2017; 33:118-124. [PMID: 27729164 DOI: 10.1016/j.arthro.2016.07.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 07/17/2016] [Accepted: 07/18/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate and compare the efficacy of intra-articular and periacetabular blocks for postoperative pain control after hip arthroscopy. METHODS Forty-two consecutive patients scheduled for hip arthroscopy were randomized into 2 postoperative pain control groups. One group received preemptive intra-articular 20 mL of bupivacaine 0.5% injection, and the second group received preemptive periacetabular 20 mL of bupivacaine 0.5% injection. Before closure all patients received an additional dose of 20 mL of bupivacaine 0.5% intra-articularly. Data were compared with respect to postoperative pain with visual analog scale (VAS) and analgesic consumption, documented in a pain diary for 2 weeks after surgery. RESULTS Twenty-one patients were treated with intra-articular injection, and 21 patients with peri-acetabular injection. There were no significant differences with regards to patient demographics or surgical procedures. VAS scores recorded during the first 30 minutes postoperatively and 18 hours after surgery were significantly lower in the periacetabular group compared with in the intra-articular group (0.667 ± 1.49 vs 2.11 ± 2.29; P < .045 and 2.62 ± 2.2 vs 4.79 ± 2.6; P < .009). There were no differences between the groups with regard to analgesic consumption. CONCLUSIONS Periacetabular injection of bupivacaine 0.5% was superior to intra-articular injection in pain reduction after hip arthroscopy at 30 minutes and 18 hours postoperatively. However, total analgesic consumption over the first 2 postoperative weeks and VAS pain measurements were not significantly affected. LEVEL OF EVIDENCE Level I, randomized controlled trial.
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Vohra S, Schlegelmilch M, Jou H, Hartfield D, Mayan M, Ohinmaa A, Wilson B, Spavor M, Grundy P. Comparative effectiveness of pediatric integrative medicine as an adjunct to usual care for pediatric inpatients of a North American tertiary care centre: A study protocol for a pragmatic cluster controlled trial. Contemp Clin Trials Commun 2016; 5:12-18. [PMID: 29740618 PMCID: PMC5936744 DOI: 10.1016/j.conctc.2016.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 11/17/2016] [Accepted: 11/22/2016] [Indexed: 11/20/2022] Open
Abstract
Background Some pediatric tertiary care centres in North America supplement conventional care with complementary therapies, together known as pediatric integrative medicine (PIM). Evidence to support the safety and efficacy of PIM is emerging, but the cost-effectiveness of an inpatient PIM service has yet to be assessed. Methods/Design This study is a pragmatic cluster controlled clinical trial. Usual care will be compared to usual care augmented with PIM in three pediatric divisions; oncology, general medicine, and cardiology at one large urban tertiary care Canadian Children's Hospital. The primary outcome of the feasibility study is enrolment; the primary outcome of the main study is cost-effectiveness. Other secondary outcomes include the prevalence and severity of key symptoms (i.e. pain, nausea/vomiting and anxiety), efficacy of PIM interventions, patient safety, and parent satisfaction. Discussion This trial will be the first to evaluate the comparative effectiveness, both clinical and cost, of a PIM inpatient service. The evidence from this study will be useful to families, clinicians and decision makers, and will describe the clinical and economic value of PIM services for pediatric patients admitted to hospital.
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Affiliation(s)
- Sunita Vohra
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 1702 College Plaza, 8215 - 112 Street NW, Edmonton, AB T6G 2C8, Canada
- Corresponding author.
| | - Michael Schlegelmilch
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 1702 College Plaza, 8215 - 112 Street NW, Edmonton, AB T6G 2C8, Canada
| | - Hsing Jou
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 1702 College Plaza, 8215 - 112 Street NW, Edmonton, AB T6G 2C8, Canada
| | - Dawn Hartfield
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-597 Edmonton Clinic Health Academy, 11405 87 Avenue, Edmonton, AB T6G 1C9, Canada
| | - Maria Mayan
- Community-University Partnership, Faculty of Extension, University of Alberta, 2-281 Enterprise Square, 10230 Jasper Avenue, Edmonton, AB T5J 4P6, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Institute of Health Economics, 1200 10405 Jasper Avenue, Edmonton, AB T5J 3N4, Canada
| | - Bev Wilson
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-516 Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada
| | - Maria Spavor
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-529 Edmonton Clinic Health Academy, 11405 87 Ave NW, Edmonton, AB T6G 1C9, Canada
| | - Paul Grundy
- Department of Pediatrics, Faculty of Medicine & Dentistry, University of Alberta, 3-469 Edmonton Clinic Health Academy, 11405-87 Ave NW, Edmonton, AB, T6G 1C9, Canada
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Gabriel RA, Wu A, Huang CC, Dutton RP, Urman RD. National incidences and predictors of inefficiencies in perioperative care. J Clin Anesth 2016; 31:238-46. [DOI: 10.1016/j.jclinane.2016.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 12/16/2015] [Accepted: 01/14/2016] [Indexed: 01/09/2023]
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