Perioperative care for the older outpatient undergoing ambulatory surgery

Add dexmedetomidine to levobupivacaine for transversus abdominis plane block in elderly patients undergoing inguinal hernia repair: Could it make a difference? A randomised trial

BACKGROUND

Transversus abdominis plane block is becoming more common as part of multimodal analgesia for post-abdominal operation pain relief. This study compared the analgesic effects of adding dexmedetomidine to levobupivacaine (transversus abdominis plane) block in elderly patients undergoing inguinal hernia surgery to adding fentanyl.

METHODS

Overall, 90 elderly patients with a simple inguinal hernia repair were randomly assigned to one of three groups. After spinal anaesthesia, an ultrasound-guided transversus abdominis plane block was performed. Transversus abdominis plane block was accomplished with 0.25% levobupivacaine + 0.9% normal saline in Group L (n = 30) (20mL). Transversus abdominis plane block was accomplished with 0.25% levobupivacaine + 1 µg/kg dexmedetomidine in Group D (n = 30) (20mL). Transversus abdominis plane block was obtained with 0.25% levobupivacaine + 1 µg/kg fentanyl in Group F (n = 30) (20mL). The primary outcome was the first analgesic request, and the secondary outcomes were the visual analog scale, postoperative analgesic requirements, sedation, hemodynamic stability, and related complications 24 hours postoperatively. 1gm paracetamol intravenously was provided as rescue analgesia.

RESULTS

The time to first analgesic request in the dexmedetomidine group was substantially more prolonged than in the fentanyl and control groups (516.5±27.8, 451.2±11.1, and 403.9±10.5min, respectively; p < 0.05). Postoperative analgesic requirements were significantly decreased in dexmedetomidine 1(1-2) than control 2(1-3) and fentanyl 1.5(1-2) respectively (P<0.01). VAS was significantly lower in Group D and Group F than in Group L postoperatively. No significant difference in side effects was noted between the groups.

CONCLUSION

The transversus abdominis plane block is the best multimodal analgesia choice for inguinal hernia repair in older patients. Combining dexmedetomidine with levobupivacaine in the transversus abdominis plane block can improve the quality of postoperative analgesia while avoiding significant side effects.

Opioid free analgesia after return home in ambulatory colonic surgery patients: a single-center observational study

BACKGROUND

Because of the adverse effects of morphine and its derivatives, non-opioid analgesia procedures are proposed after outpatient surgery. Without opioids, the ability to provide quality analgesia after the patient returns home may be questioned. We examined whether an opioid-free strategy could ensure satisfactory analgesia after ambulatory laparoscopic colectomy.

METHODS

We performed a retrospective observational single-center study (of prospective collected database) including all patients eligible for scheduled outpatient colectomy. Postoperative analgesia was provided by paracetamol and nefopam. Postoperative follow-up included pain at mobilization (assessed by a numerical rating scale, NRS), hemodynamic variables, temperature, resumption of transit and biological markers of postoperative inflammation. The primary outcome was the proportion of patients with moderate to severe pain (NRS > 4) the day after surgery.

RESULTS

Data from 144 patients were analyzed. The majority were men aged 59 ± 12 years with a mean BMI of 27 [25-30] kg/m2. ASA scores were 1 for 14%, 2 for 59% and 3 for 27% of patients. Forty-seven patients (33%) underwent surgery for cancer, 94 for sigmoiditis (65%) and 3 (2%) for another colonic pathology. Postoperative pain was affected by time since surgery (Q3 = 52.4,p < 0.001) and decreased significantly from day to day. The incidence of moderate to severe pain at mobilization (NRS > 4) on the first day after surgery was (0.19; 95% CI, 0.13-0.27).

CONCLUSION

Non-opioid analgesia after ambulatory laparoscopic colectomy seems efficient to ensure adequate analgesia. This therapeutic strategy makes it possible to avoid the adverse effects of opioids.

TRIAL REGISTRATION

The study was retrospectively registered and approved by the relevant institutional review board (CERAR) reference IRB 00010254-2018 - 188). All patients gave written informed consent for analysis of their data. The anonymous database was declared to the French Data Protection Authority (CNIL) (reference 221 2976 v0 of April 12, 2019).

Endoscopic Hip Abductor Tendon Repair Results in Successful Outcomes With 5- to 10-Year Follow-Up

PURPOSE

To report the outcomes of endoscopic repair in a consecutive series of patients with follow-up ranging from 5 to 10 years.

METHODS

Sixty-five consecutive hips in 63 patients (2 bilateral) undergoing endoscopic abductor tendon repair with minimum 5-year follow-up were assessed with the modified Harris Hip Score. The minimal clinically important difference (MCID) was determined as one-half the standard deviation of the amount of improvement.

RESULTS

The mean age was 56.6 years (standard deviation [SD], 11.3 years), with 58 female and 5 male patients. Follow-up was obtained on 64 hips (98.5%) at a mean of 85 months (SD, 15.7 months). There were 33 full-thickness and 32 partial-thickness tears, with 40 gluteus medius tears, 23 medius and minimus tears, and 2 isolated minimus tears. Concomitant arthroscopy of the hip joint was performed in 50 patients (52 hips), including 15 with correction of femoroacetabular impingement. The mean modified Harris Hip Score was 48.4 (SD, 15.7) preoperatively and 83.4 (SD, 15.9) postoperatively, reflecting a mean improvement of 34.9 (95% confidence interval, 34.9 ± 4.3), with 92.2% of patients achieving the MCID of 8.7. There were no complications. Three patients underwent further surgery: One underwent total hip replacement at 11 months after abductor repair, one underwent repeated arthroscopy for joint debridement at 12 months after repair, and one underwent revision abductor repair at 6 years postoperatively.

CONCLUSIONS

Collectively, with 5- to 10-year follow-up, patients undergoing endoscopic abductor tendon repair can respond exceptionally well, with 92.2% achieving the MCID, even among a heterogeneous group of partial- and full-thickness tears with single- and 2-tendon involvement undergoing single- and double-row repair.

LEVEL OF EVIDENCE

Level IV, case series.

Association between obesity and risk of delayed discharge and unplanned readmission for day surgery: A systematic review and meta-analysis

AIMS

This work aims to investigate the association between obesity and risk of delayed discharge and unplanned readmission in day surgery patients.

BACKGROUND

Day surgeries are well received and developing rapidly. Associations between obesity and delayed discharge and unplanned readmission, which are clinically relevant outcomes in day surgeries, are complex.

DESIGN

A systematic review and meta-analysis was conducted.

DATA SOURCES

The PubMed, Web of Science, EMBASE, Cochrane Library, CNKI, VIP, and Wan Fang databases were comprehensively searched from inception until January 2021.

REVIEW METHODS

Two independent reviewers assessed the studies and extracted data. Pooled estimates were obtained using a random-effects model.

RESULTS

Eleven articles published between 2007 and 2020 were finally included. Obesity appeared not to increase the risk of delayed discharge. However, morbid obesity seemed to be associated with a higher risk of delayed discharge. The meta-analysis revealed no relationship between higher body mass index (BMI) and unplanned readmission for day surgery patients.

CONCLUSIONS

Obesity appeared not to increase the risk of delayed discharge except in patients with morbid obesity. Additionally, a higher BMI was not associated with increased risk of unplanned readmission after day surgery. Future studies are required to address this issue further in different types of surgery and areas.

Predictors and outcomes of same day discharge after minimally invasive hysterectomy in gynecologic oncology within the National Surgical Quality Improvement Program database

OBJECTIVE

To assess trends over time of same day discharge after minimally invasive hysterectomy in oncology, identify perioperative factors influencing same day discharge, and evaluate 30 day postoperative morbidity.

METHODS

A retrospective cohort of elective minimally invasive hysterectomies performed for gynecologic oncologic indications between January 2013 and December 2021 was identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Clinical and surgical characteristics, length of stay, and 30 day postoperative complications were captured. Clinical and surgical factors affecting same day discharge rate and impact of same day discharge on postoperative outcomes were evaluated using χ2 tests and logistic regression.

RESULTS

Patients undergoing minimally invasive hysterectomy (n=32 823) had a same day discharge rate of 34.5% over the 9 year period, increasing from 15.5% in 2013 to 55.1% in 2021. The rate of patients discharged on postoperative day 1 decreased from 76.4% to 41.4% over this period. On multivariable analysis, same day discharge decreased with: age 70-79 years (odds ratio (OR) 0.80) and ≥80 years (OR 0.42); body mass index 40-49.9 kg/m2 (OR 0.89) and ≥50 kg/m2 (OR 0.67); patient comorbidities, including hypertension (OR 0.85), chronic steroid use (OR 0.74), bleeding disorder (OR 0.54), anemia (OR 0.89), and hypoalbuminemia (OR 0.76); and surgical time >90th percentile (OR 0.40) (all p<0.05). Lymphadenectomy did not impact the same day discharge rate (unadjusted OR 1.03, p=0.22). Same day discharge had no effect on 30 day postoperative composite morbidity (OR 0.91, p=0.20), and was associated with fewer readmissions (OR 0.75, p=0.005). Age 70-79 years (OR 1.07, p=0.435) and age ≥80 years (OR 1.11, p=0.504) did not increase postoperative morbidity. However, body mass index categories 40-49.9 kg/m2 (OR 1.28, 95% CI 1.08 to 1.51) and ≥50 kg/m2 (OR 1.60, 95% CI 1.27 to 2.01) were associated with greater 30 day composite morbidity.

CONCLUSION

In this study, same day discharge following minimally invasive hysterectomy for oncologic indications was safe, and rates are rising among all age and body mass index categories. Quality improvement initiatives are needed at oncology centers to promote early discharge after minimally invasive gynecologic oncology surgery.

Ambulatory anesthesia: restructuring for success

PURPOSE OF REVIEW

We review current evidence about organizational structures, patient selection criteria, safety measures, economic considerations, quality management, and staffing challenges in ambulatory anesthesia. The focus is on the facilitators and barriers related to the peri-interventional period and the potential concepts and innovations for the future development of ambulatory anesthesia services.

RECENT FINDINGS

Recent findings shed light on organizational structures in ambulatory anesthesia, including hospital-based centers, freestanding ambulatory centers, and office-based practices. Patient selection for ambulatory anesthesia involves a two-step process, considering both surgical and anesthetic factors. Safety measures, such as standardized guidelines and scoring systems, aim to ensure patient well being during the perioperative course. Economic considerations pose challenges due to the complexities of managing operating room efficiency and the variations in reimbursement systems. Quality management in ambulatory anesthesia emphasizes the need for outcome studies and patient-centered quality indicators. Staffing requirements necessitate highly skilled professionals with both technical and nontechnical skills, and structured education and training are essential.

SUMMARY

Ambulatory anesthesia is gaining importance due to advancements in surgical techniques and peri-interventional care. The review highlights the need for addressing challenges related to organizational structures, patient selection, patient safety, economic considerations, quality management, and staffing in ambulatory anesthesia. Understanding and addressing these factors are crucial for promoting the further development and improvement of ambulatory anesthesia services.

The Analgesic Effects of Preemptive Ultrasound-Guided Pericapsular Nerve Group Block in Comparison with Erector Spinae Plane Block in Elderly Undergoing Hip Arthroplasty: A Randomized Controlled Trial

Background

Perioperative pain management strategies in the elderly undergoing hip arthroplasty need special and safe preemptive care.

Objectives

The primary aim of this study was to compare the analgesic effects of preemptive ultrasound-guided pericapsular nerve group (PENG) block and lumbar erector spinae plane block (L-ESPB) in the elderly undergoing hip arthroplasty. The time to the first postoperative rescue analgesia was measured. The secondary aim was to assess the ease of spinal positioning (EOSP), onset of sensory block, block performance time, and patient satisfaction.

Methods

Before positioning for spinal anesthesia, 69 elderly patients undergoing hip arthroplasty were randomized into three groups (n = 23 per group). The first intervention group received ultrasound-guided PENG block with 20 mL bupivacaine 0.25%; the second intervention group received ultrasound-guided L-ESPB using the same dose of bupivacaine. In the control group, patients received spinal anesthesia without any block.

Results

The time to first postoperative rescue analgesic (morphine) was significantly prolonged in the PENG group (13.3 ± 3.5 h) compared to the L-ESPB (9.5 ± 2.3 h) and control (2.6 ± 0.4 h) groups. The EOSP score was significantly higher in the PENG group compared to the L-ESPB and control groups (P < 0.001). The block performance time and oneset of the sensory block were significantly shorter in the PENG group compared to the L-ESPB group. The highest patient satisfaction scores were observed in the PENG group.

Conclusions

Preemptive pericapsular nerve group block postponed the need for postoperative analgesia and eased spinal positioning compared to L-ESPB in the elderly undergoing hip arthroplasty.

The future of ambulatory surgery for geriatric patients

The elderly segment of the population is growing rapidly worldwide. Older patients comprise a disproportionate percentage of the surgical caseload. Physiological changes are inevitable with aging; some may impact a patient's response to anesthesia and surgery. Careful evaluation of an elderly patient preoperatively is vital to proper patient selection for ambulatory surgeries, particularly for complex and lengthy procedures. Cognitive issues, frailty, and geriatric syndromes make a patient vulnerable and sometimes unsuitable for certain ambulatory procedures. Preoperative planning and interventions may improve outcomes for the elderly patient undergoing ambulatory surgery.

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications

ABSTRACT

The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.

Intensive care in an older population: Influence of age, comorbidities and sex in 304 plastic and reconstructive surgical patients older than 75 years

AIM

An aging population will lead to an increasing demand for critical care resources. Hence, we evaluated the potential influence of age, comorbidities and sex in plastic and reconstructive patients ≥75 years that were admitted to the intensive care unit (ICU).

METHODS

We included 304 patients who required intensive care between 2000 and 2019. Besides patient demographics, medical case characteristics were statistically evaluated.

RESULTS

In this study, 184 patients were female (61%) (120 male), the median age was 81.8 years (25th and 75th percentiles: 77.4-87.2) with a range of 75.0-98.9 years. The median length of stay in the ICU was 12 days (25th and 75th percentiles: 3-28) with a range of 0-382 days. The reasons for admission were burn injury (n = 230, 76%), necrotizing fasciitis (n = 34, 11%), non-combustion-related traumas (n = 22, 7%) and postoperative observation after plastic surgery procedures (n = 18, 6%). In total, 108 patients (36%), who were significantly older (P = 0.005) and had a significantly shorter stay (P < 0.001) compared with the surviving cohort, died during their stay in the ICU. Our multivariable logistic regression model revealed that age (odds ratio: 1.05 [1.01, 1.09]; P = 0.017) and number of operations (odds ratio: 0.75 [0.60, 0.96]; P = 0.023) were significant predictors for death in the ICU.

DISCUSSION

Age plays a critical role in determining fatal outcome of old patients requiring intensive care. In contrast, sex and number of comorbidities shows no significant influence. Geriatr Gerontol Int 2022; ••: ••-••.

Emergencies in freestanding ambulatory surgery centre

PURPOSE OF REVIEW

Ambulatory surgery is increasing, more procedures as well as more complex procedures are transferred to ambulatory surgery. Patients of all ages including elderly and more fragile are nowadays scheduled for ambulatory surgery. Enhanced recovery after surgery (ERAS) protocols are now developed for further facilitating readily recovery, ambulation, and discharge. Thus, to secure safety, a vigilant planning and preparedness for adverse events and emergencies is mandatory.

RECENT FINDINGS

Proper preoperative assessment, preparation/optimization and collaboration between anaesthetist and surgeon to plan for the optimal perioperative handling has become basic to facilitate well tolerated perioperative course. Standard operating procedures for rare emergencies must be in place. These SOPs should be trained and retrained on a regular basis to secure safety. Check lists and cognitive aids are tools to help improving safety. Audit and analysis of adverse outcomes and deviations is likewise of importance to continuously analyse and implement corrective activity plans whenever needed.

SUMMARY

The present review will provide an oversight of aspects that needs to be acknowledged around planning handling of rare but serious emergencies to secure quality and safety of care in freestanding ambulatory settings.

Postoperative Pain as a Decision-Making Tool in Treating Hemorrhoids on an In- or Out-Patient Basis After Stapled Mucosectomy (Longo Procedure)

Objective

Stapled mucosectomy (Longo operation) is a frequently used procedure for the treatment of hemorrhoidal disease. It is a simple procedure yet similar to resective techniques for patients who frequently suffer from relevant postoperative pain. The aim of our present study is to examine patient satisfaction based on the operative setting (outpatient versus inpatient treatment) in patients undergoing the Longo operation for Grade III or IV hemorrhoids.

Materials and methods

Outcomes of all patients undergoing stapled mucosectomy for Grade III and IV hemorrhoids at 3 different Swiss public hospitals was analyzed retrospectively and compared with respect to in- or outpatient treatment. Patient satisfaction was recorded by subsequent telephone interviews.

Results

From a total of 213 patients with stapled mucosectomies, datasets of 144 patients (67.6%) were available for full analysis. A total of 124 patients (86.1%) were satisfied with the treatment and 110 (76%) would choose to undergo the Longo procedure again (P &lt; 0.01). Recurrence of recurrent hemorrhoidal symptoms is negatively correlated with the willingness of undergoing the Longo procedure again (r = −0.187, P = 0.025). Patient satisfaction was not associated with the operative setting (inpatient vs. out-patient setting). Postoperative pain increased the willingness to be hospitalized overnight (r = 0.227, P &lt; 0.01).

Conclusion

Patient satisfaction after stapled mucosectomy is mainly related to postoperative pain and recurrence of hemorrhoidal symptoms regardless of inpatient or outpatient treatment.

Postoperative infectious complications in elderly patients after elective surgery in China: results of a 7-day cohort study from the International Surgical Outcomes Study

AIM

Despite initiatives to increase elderly patients' access to surgical treatments, the prevalence and impact of postoperative infectious complications (PICs) in elderly patients in China are poorly described. The aim of our study was to describe PICs and associated mortality in elderly patients undertaking elective surgery in China.

METHODS

We analyzed data about elderly patients from China during the International Surgical Outcomes Study (ISOS), a 7-day prospective cohort study of outcomes after elective surgery in in-patient adults. All elderly patients (age ≥60 years) from 28 hospitals in China included in the ISOS study were included in this study as well. A review of 2014 elderly patients who underwent elective surgery in April 2014 was conducted.

RESULTS

Of 2014 elderly patients, 209 (10.4%) developed at least one postoperative complication. Infectious complications were most frequent, affecting 154 patients (7.6%); there was one death, or 0.6% 30-day mortality, which was a significantly higher rate than among patients without PICs (0%). The most frequent infectious complication was superficial surgical-site infection (3.3%). The length of hospital stay was longer in elderly patients with PICs than in those without PICs. Moreover, a total of 142 elderly patients (7.1%) were routinely sent to critical care after surgery, of whom 97 (68.3%) developed PICs. Compared to elderly patients admitted to a standard ward, those admitted to critical care immediately after surgery had a higher postoperative complication rate and critical care admission rate to treat complications.

CONCLUSIONS

The present prospective, multicentre study found that 7.6% of elderly patients in China had PICs after elective surgery that could prolong hospital stay and increase 30-day mortality. The clinical effectiveness of admission to critical care after surgery on elderly patients is not identified. Initiatives to increase elderly patients' access to surgical interventions should also enhance safe perioperative care to reduce PICs in China.

Nulla Per Os (NPO) guidelines: time to revisit?

PURPOSE OF REVIEW

Preoperative fasting guidelines are generalized to elective procedures and usually do not distinguish between the ambulatory and inpatient setting. Prevalence of aspiration is low while prolonged preoperative fasting is common clinical reality. Recently, changes in preoperative fasting guidelines have been widely discussed.

RECENT FINDINGS

Rates of prolonged clear fluid fasting (>4 h) prior to surgery are reported in up to 80% of patients with mean fasting duration of up to 16 h and beyond. Prolonged fasting may result in adverse effects such as intraoperative hemodynamic instability, postoperative delirium, patient discomfort, and extended hospital length of stay. Liberal approaches allowing clear fluids up to 1 h prior to anesthesia or until premedication/call to the operating room have shown no increase in adverse events among children. Various anesthesia societies now encourage clear fluid intake up to 1 h prior to pediatric elective anesthesia. Similar reports in the adult cohort are scarce.

SUMMARY

Allowing sips of water until call to the operating room may help reducing prolonged preoperative fasting and improving patient comfort while keeping a flexibility in operating room schedule. The feasibility and safety of a liberal clear fluid fasting regimen among adults undergoing elective anesthesia needs to be evaluated in future studies.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient’s risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Discrepancy and contradiction regarding fixation of hip stems with or without cement: survey among 765 hip arthroplasty specialists

INTRODUCTION

The growing use of cementless stems is associated with an increase in implant-related complications. This global survey study investigates which parameters orthopaedic surgeons currently consider for either cemented or cementless stem fixation in primary total hip arthroplasty (THA).

METHODS

A survey regarding current practice patterns was distributed among hip arthroplasty specialists. Key questions concerned: (i) frequency of using cemented/cementless stems; (ii) frequency of using parameters which influence a choice between both; (iii) usage of specific cut-off values for parameters.

RESULTS

507 (out of 765) respondents, having at least 5 years' experience and performing at least 50 cases a year, were selected for analysis. Respondents using both fixation techniques ( n = 413; 81%) use a cementless stem in 69% and a cemented stem in 31%. The choice is most frequently based on: (i) patient age; (ii) cortical thickness; (iii) femoral canal shape; (iv) bone mineral density; and (v) stem fit on preoperative templating. 57% using both fixation techniques do not use a specific cut-off value for age. 92% of the respondents that do use a cut-off value for age use exclusively cemented stems in patients being ⩾72.7 years (median 75; range 50-90 years). Considerable discrepancy and even contradictory responses were present regarding the other parameters and the use of specific cut-off values.

CONCLUSIONS

Current practice patterns regarding stem fixation in primary THA vary substantially among orthopaedic surgeons. Evidence-based guidelines are needed to define which parameters and threshold values support the best individual choice for hip stem fixation.

Efficacy of external nasal nerve block following nasal surgery : A randomized, controlled trial

BACKGROUND

Pain is the major determinant factor which affects the quality of recovery and postoperative agitation following nasal surgery with the patient under general anesthesia. Our objectives were to test the hypothesis that an external nasal nerve block will decrease pain intensity, decrease drug consumption, decrease the incidence of postoperative emergence agitation and improve quality of recovery.

MATERIAL AND METHODS

In this study 100 adult patients who were scheduled for elective external nasal surgery with the patient under general anesthesia and nasal packing on each side, received external nasal nerve blocks postoperatively for 24 h with saline (group I) or 2% xylocaine (group II) with 1:200,000 epinephrine. Postoperative pain was measured at the postanesthesia care unit (PACU) utilizing a visual analog scale (VAS). Narcotics consumption was also measured. Emergence agitation and quality of recovery were also assessed.

RESULTS

Pain scores were statistically significant between both groups. Requirements of equivalent morphine doses in the PACU were lower in group II (block) than group I (control) with a significant P value <0.001. Group II (block) patients required significantly less intraoperative fentanyl than group I (control) patients (p = 0.001). Group II (block) showed higher scores in pain dimension of QoR-40 in comparison with group I (P <0.001). The incidence of emergence agitation was lower in group II (block) than in group I (control, 24% vs. 48%, P = 0.012).

CONCLUSION

External nasal nerve block is an effective technique for reducing postoperative pain, drug consumption and quality of recovery. It also reduces emergence agitation. The effects are mainly due to profound analgesia and effective pain control that lead to decreased drug usage and reduced discomfort.

Associations of Fluid Amount, Type, and Balance and Acute Kidney Injury in Patients Undergoing Major Surgery

Fluid administration has been reported to be associated with an increased risk of acute kidney injury (AKI). We assessed whether, after correction for fluid balance, amount and chloride content of fluids administered have an independent association with AKI. We performed an observational study in patients after major surgery assessing the independent association of AKI with volume, chloride content and fluid balance, after adjustment for Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) score, age, elective versus emergency surgery, and duration of surgery. We studied 542 consecutive patients undergoing major surgery. Of these, 476 patients had renal function tested as part of routine clinical care and 53 patients (11.1%) developed postoperative AKI. After adjustments, a 100 ml greater mean daily fluid balance was artificially associated with a 5% decrease in the instantaneous hazard of AKI: adjusted Hazard Ratio (aHR) 0.951, 95% confidence intervals (CI) 0.935 to 0.967, P <0.001. However, after adjustment for the proportion of chloride-restrictive fluids, mean daily fluid amounts and balances, POSSUM morbidity, age, duration and emergency status of surgery, and the confounding effect of fluid balance, every 5% increase in the proportion of chloride-liberal fluid administered was associated with an 8% increase in the instantaneous hazard of AKI (aHR 1.079, 95% CI 1.032 to 1.128, P=0.001), and a 100 ml increase in mean daily fluid amount given was associated with a 6% increase in the instantaneous hazard of AKI (aHR 1.061, 95% CI 1.047 to 1.075, P <0.001). After adjusting for key risk factors and for the confounding effect of fluid balance, greater fluid administration and greater administration of chloride-rich fluid were associated with greater risk of AKI.

Profile of sugammadex for reversal of neuromuscular blockade in the elderly: current perspectives

The number of elderly patients is increasing worldwide. This will have a significant impact on the practice of anesthesia in future decades. Anesthesiologists must provide care for an increasing number of elderly patients, who have an elevated risk of perioperative morbidity and mortality. Complications related to postoperative residual neuromuscular blockade, such as muscle weakness, airway obstruction, hypoxemia, atelectasis, pneumonia, and acute respiratory failure, are more frequent in older than in younger patients. Therefore, neuromuscular blockade in the elderly should be carefully monitored and completely reversed before awakening patients at the end of anesthesia. Acetylcholinesterase inhibitors are traditionally used for reversal of neuromuscular blockade. Although the risk of residual neuromuscular blockade is reduced by reversal with neostigmine, it continues to complicate the postoperative course. Sugammadex represents an innovative approach to reversal of neuromuscular blockade induced by aminosteroid neuromuscular-blocking agents, particularly rocuronium, with useful applications in clinical practice. However, aging is associated with certain changes in the pharmacokinetics of sugammadex, and to date there has been no thorough evaluation of the use of sugammadex in elderly patients. The aim of this review was to perform an analysis of the use of sugammadex in older adults based on the current literature. Major issues surrounding the physiologic and pharmacologic effects of aging in elderly patients and how these may impact the routine use of sugammadex in elderly patients are discussed.

External Validation and Modification of a Predictive Model for Acute Postsurgical Pain at Home After Day Surgery

OBJECTIVES

In 2009, Gramke and colleagues have described predictive factors to preoperatively detect those at risk for moderate to severe acute postsurgical pain (APSP) after day surgery. The aim of the present study is to externally validate this initial model and to improve and internally validate a modified version of this model.

MATERIALS AND METHODS

Elective patients scheduled for day surgery were prospectively enrolled from November 2008 to April 2010. Model discrimination was quantified using the area under the receiver operating characteristic curve (AUC). Model calibration was assessed by visual inspection of the calibration plot. Subsequently, we modified (different assignment of type of surgery, different cutoff for moderate to severe APSP, continuous of dichotomized variables and testing of additional variables) and internally validated this model by standard bootstrapping techniques.

RESULTS

A total of 1118 patients were included. The AUC for the original model was 0.81 in the derivation data set and 0.72 in our validation data set. The model showed poorly calibrated risk predictions. The AUC of the modified model was 0.82 (optimism-corrected AUC=0.78). This modified model showed good calibration.

CONCLUSIONS

The original prediction model of Gramke and colleagues performed insufficiently on our cohort of outpatients with respect to discrimination and calibration. Internal validation of a modified model shows promising results. In this model, preoperative pain, patient derived expected pain, and different types of surgery are the strongest predictors of moderate to severe APSP after day surgery.

Analgesic Plasma Concentrations of Oxycodone After Surgery for Breast Cancer-Which Factors Matter?

We investigated factors affecting analgesic oxycodone concentrations after breast cancer surgery in 1,000 women. Preoperatively, we studied heat and cold pain sensitivities and anxiety scores. Postoperatively, rest and motion pain intensities were measured and intravenous oxycodone was administered until satisfactory analgesia. At this point, the mean oxycodone concentration (variation coefficient) was 33.3 ng/mL (66%) and it was 21.7 ng/mL (69%) when the patient requested oxycodone again. At both time points, the concentrations varied >100-fold between individuals. The analgesic oxycodone concentration was increased by 21.3% per motion pain intensity score on a 0-10 scale and by 22.3% if axillary clearance was performed instead of sentinel node biopsy (P < 0.001). Forty-seven women who were older and less anxious than others (P < 0.01) required no oxycodone. Anxiety, age, chronic pain, or preoperative pain sensitivity were not independently associated with the analgesic oxycodone concentration. CYP2D6 and CYP3A genotypes did not affect analgesic concentration or duration of analgesia.

Perioperative Care of Elderly Surgical Outpatients

The ambulatory setting offers potential advantages for elderly patients undergoing elective surgery due to the advancement in both surgical and anesthetic techniques resulting in quicker recovery times, fewer complications, higher patient satisfaction, and reduced costs of care. This review article aims to provide a practical guide to anesthetic management of elderly outpatients. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative complications (e.g., pain, postoperative nausea and vomiting [PONV], delirium and cognitive dysfunction, and gastrointestinal dysfunction) are discussed. The role of anesthesiologists as perioperative physicians is important for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. The implementation of high-quality, evidence-based perioperative care programs for the elderly on an ambulatory basis has assumed increased importance. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving enhanced recovery after surgery.

An update on the management of postoperative nausea and vomiting

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. PONV and PDNV can delay discharge and recovery and increase medical costs. The high incidence of PONV has persisted in part because of the tremendous growth in ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major operations. Pharmacological management of PONV should be tailored to the patients' risk level using the PONV and PDNV scoring systems to minimize the potential for these adverse side effects in the postoperative period. A combination of prophylactic antiemetic drugs should be administered to patients with moderate-to-high risk of developing PONV in order to facilitate the recovery process. Optimal management of perioperative pain using opioid-sparing multimodal analgesic techniques and preventing PONV using prophylactic antiemetics are key elements for achieving an enhanced recovery after surgery. Strategies that include reductions of the baseline risk (e.g., adequate hydration, use of opioid-sparing analgesic techniques) as well as a multimodal antiemetic regimen will improve the likelihood of preventing both PONV and PDNV.

An update on pain management for elderly patients undergoing ambulatory surgery

PURPOSE OF REVIEW

The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting.

RECENT FINDINGS

Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h.

SUMMARY

The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.

Use of Transversus Abdominis Plane (TAP) Blocks for Pain Management in Elderly Surgical Patients

Elderly patients who require surgical interventions often have multiple comorbidities that complicate their intraoperative and postoperative care. Surgical team members should consider all potential problems that elderly patients may experience and base perioperative care on their assessment. This article discusses the use of the transversus abdominis plane (TAP) block in elderly patients undergoing surgical procedures to relieve pain and reduce the use of narcotics or sedatives during the immediate and extended postoperative recovery period. By reducing postoperative pain and the use of sedatives and narcotics, the TAP block improves pain management and helps reduce the incidence of postoperative delirium, pneumonia, urinary retention, and falls.

Practice variations in voice treatment selection following vocal fold mucosal resection

OBJECTIVES/HYPOTHESIS

To characterize initial voice treatment selection following vocal fold mucosal resection in a Medicare population.

STUDY DESIGN

Retrospective analysis of a large, nationally representative Medicare claims database.

METHODS

Patients with > 12 months of continuous Medicare coverage who underwent a leukoplakia- or cancer-related vocal fold mucosal resection (index) procedure during calendar years 2004 to 2009 were studied. The primary outcome of interest was receipt of initial voice treatment (thyroplasty, vocal fold injection, or speech therapy) following the index procedure. We evaluated the cumulative incidence of each postindex treatment type, treating the other treatment types as competing risks, and further evaluated postindex treatment utilization using the proportional hazards model for the subdistribution of a competing risk. Patient age, sex, and Medicaid eligibility were used as predictors.

RESULTS

A total of 2,041 patients underwent 2,427 index procedures during the study period. In 14% of cases, an initial voice treatment event was identified. Women were significantly less likely to receive surgical or behavioral treatment compared to men. From age 65 to 75 years, the likelihood of undergoing surgical treatment increased significantly with each 5-year age increase; after age 75 years, the likelihood of undergoing either surgical or behavioral treatment decreased significantly every 5 years. Patients with low socioeconomic status were significantly less likely to undergo speech therapy.

CONCLUSION

The majority of Medicare patients do not undergo voice treatment following vocal fold mucosal resection. Further, the treatments analyzed here appear disproportionally utilized based on patient sex, age, and socioeconomic status. Additional research is needed to determine whether these observations reflect clinically explainable differences or disparities in care.

LEVEL OF EVIDENCE

2c. Laryngoscope, 126:2505-2512, 2016.

Postanesthesia Care for the Elderly Patient

PURPOSE

As the general population lives longer, the perioperative physician is more likely to encounter disease states that increase in incidence in an aging population. This review focuses on anesthetic considerations for rational drug choices during the perioperative care of elderly patients. The primary aim of the review was to identify intraoperative and postanesthetic considerations for diseases associated with advancing age; it includes highlights of the commonly impaired major organs (eg, cardiovascular, pulmonary, neurologic, renal, hepatic systems). We also outline an approach to frequent issues that arise in the immediate postsurgical period while caring for these patients.

METHODS

A systematic review was performed on aspects of the perioperative and postoperative periods that relate to the elderly. A list of pertinent key words was derived from the authors, and a PubMed database search was performed.

FINDINGS

The anesthesiologist must account for changes in various organ systems that affect perioperative care, including the cardiovascular, pulmonary, renal, hepatic, and central nervous systems. The pharmacokinetic principles frequently differ and are often unpredictable because of anatomic changes and decreased renal and hepatic function. The most important pharmacodynamic consideration is that elderly patients tend to exhibit an exaggerated hypoactivity after anesthesia.

IMPLICATIONS

Before surgery, it is essential to identify those patients at risk for delirium and other commonly encountered postanesthesia scenarios. Failure to manage these conditions appropriately can lead to an escalation of care and prolonged hospitalization.

Prevalence and Predictors of Quality of Recovery at Home After Day Surgery

Traditionally, major complications and unanticipated admission/readmission rates were used to assess outcome after day surgery. However, in view of the relative absence of major complications the quality of recovery (QOR) should be considered one of the principal endpoints after day surgery. In our study, the level of QOR is defined by a combination of the Global Surgical Recovery (GSR) Index and the Quality of Life (QOL). The aim of this study was to analyze prevalence and predictors of QOR after day surgery on the fourth postoperative day. Elective patients scheduled for day surgery from November 2008 to April 2010 were enrolled in a prospective cohort study. Outcome parameters were measured by using questionnaire packages at 2 time points: 1 week preoperatively and 4 days postoperatively. Primary outcome parameter is the QOR and is defined as good if the GSR index >80% as well as the postoperative QOL is unchanged or improved as compared with baseline. QOR is defined as poor if both the GSR index ≤ 80% and if the postoperative QOL is decreased as compared with baseline. QOR is defined as intermediate in all other cases. Three logistic regression analyses were performed to determine predictors for poor QOR after day surgery. A total of 1118 patients were included. A good QOR was noted in 17.3% of patients, an intermediate QOR in 34.8%, and a poor QOR in 47.8% 4 days after day surgery. The best predictor for poor QOR after day surgery was type of surgery. Other predictors were younger age, work status, and longer duration of surgery. A history of previous surgery, expected pain (by the patient) and high long-term surgical fear were significant predictors of poor QOR in only 1 of 3 prediction models. The QOR at home 4 days after day surgery was poor in the majority of patients and showed a significant procedure-specific variation. Patients at risk for poor QOR can be identified during the preoperative period based on type of surgery, age, work status, and the duration of the surgery.

Anesthesia for the elderly outpatient

PURPOSE OF REVIEW

As the number of ambulatory surgery procedures continues to grow in an aging global society, the implementation of evidence-based perioperative care programs for the elderly patients will assume increased importance.

RECENT FINDINGS

Increasing evidence supports the expanded use of ambulatory surgery for managing elderly patients undergoing elective surgery procedures.

SUMMARY

This review article describes the demographics of ambulatory surgery in the elderly population. This review article describes the effects of aging on the responses of geriatric patients to anesthetic and analgesic drugs used during ambulatory surgery. Important considerations in the preoperative evaluation of elderly outpatients with co-existing diseases, as well as the advantages and disadvantages of different anesthetic techniques on a procedural-specific basis, and recommendations regarding the management of common postoperative side-effects (including delirium and cognitive dysfunction, fatigue, dizziness, pain, and gastrointestinal dysfunction) after ambulatory surgery. Finally, we discuss the future challenges related to the continued expansion of ambulatory surgery practice in this growing segment of our surgical population. The role of anesthesiologists as perioperative physicians is of critical importance for optimizing surgical outcomes for elderly patients undergoing ambulatory surgery. Providing high-quality, evidence-based anesthetic and analgesic care for elderly patients undergoing elective operations on an ambulatory basis will assume greater importance in the future.

Perioperative management of elderly patients

The older population only represents 13.7% of the US population but has grown by 21% since 2002. The centenarian population is growing at a faster rate than the total US population. This unprecedented growth has significantly increased surgical demand. The establishment of quality and performance improvement data has allowed researchers to focus attention on the older patient population, resulting in an exponential increase in studies. Although there is still much work to be done in this field, overlying themes regarding the perioperative management of elderly patients are presented in this article based on a thorough literature review.

Modified sevoflurane-based sedation technique versus propofol sedation technique: A randomized-controlled study

Background:

The aim of this study was to evaluate the safety and efficacy of sevoflurane-based sedation technique for colonoscopy in geriatric patients as compared with that using propofol.

Materials and Methods:

Sixty elderly patients, who were scheduled for colonoscopy, participated in this controlled prospective study and were randomly allocated into two groups; P and S. The patients were sedated using either propofol in P group or sevoflurane in S group. Complications (including apnea, the need for airway intervention, occurrence of general anesthesia [GA], hemodynamic instability and others), the fentanyl requirement and the times of the procedure, recovery, and discharge were recorded in both groups.

Results:

The patients in P group had more frequent apnea attacks, need for airway intervention and occurrence of GA compared to the patients in S group. However, both groups were comparable regarding the other measured variables.

Conclusion:

For geriatric colonoscopy, sevoflurane can provide safe and effective sedation alternative to propofol.

Brief review: Adoption of electronic medical records to enhance acute pain management

PURPOSE

The purpose of this paper is to examine physician barriers to adopting electronic medical records (EMRs) as well as anesthesiologists' experiences with the EMRs used by the acute pain management service at two tertiary care centres in Canada.

SOURCE

We first review the recent literature to determine if physician barriers to adoption are changing given the exponential growth of information technology and the evolving healthcare environment. We next report on institutional experience from two academic health sciences centres regarding the challenges they encountered over the past ten years in developing and implementing an electronic medical record system for acute pain management.

PRINCIPAL FINDINGS

The key identified barriers to adoption of EMRs are financial, technological, and time constraints. These barriers are identical to those reported in a systematic review performed prior to 2009 and remain significant factors challenging implementation. These challenges were encountered during our institution's process of adopting EMRs specific to acute pain management. In addition, our findings emphasize the importance of physician participation in the development and implementation stages of EMRs in order to incorporate their feedback and ensure the EMR system is in keeping with their workflow.

CONCLUSIONS

Use of EMRs will inevitably become the standard of care; however, many barriers persist to impede their implementation and adoption. These challenges to implementation can be facilitated by a corporate strategy for change that acknowledges the barriers and provides the resources for implementation. Adoption will facilitate benefits in communication, patient management, research, and improved patient safety.

High early failure rate after cementless hip replacement in the octogenarian

BACKGROUND

Use of cementless hip replacements is increasing in many countries, but the best method for fixation for octogenarian patients remains unknown.

QUESTIONS/PURPOSES

We studied how fixation method (cemented, cementless, hybrid) affects the survival of primary hip replacements and mortality in patients 80 years or older. Specifically, we asked if fixation method affects (1) the risk of revision; (2) the reasons for revision; and (3) the mortality after contemporary primary hip replacement in octogenarian patients.

METHODS

A total of 4777 primary total hip replacements were performed in 4509 octogenarian patients with primary osteoarthritis in Finland between 1998 and 2009 and were registered in the Finnish Arthroplasty Register. Comorbidity data were collected from a nationwide quality register. Survival of hip replacements, using any revision as the end point, and mortality were analyzed using competing risks survival analysis and Cox regression analysis. The average followup was 4 years (range, 1-13 years).

RESULTS

Cementless hip replacements were associated with a higher rate of early (within 1 year) revision compared with cemented hip replacements (hazard ratio, 2.9; 95% CI, 1.7-5.1), particularly in women. The difference was not explained by comorbidity or provider-related factors. Periprosthetic fracture was the leading mode of failure of cementless hip replacements. After 1 year, there were no differences in the survival rates although 10-year survival was slightly lower for cementless than cemented and hybrid hip replacements (93.9% [95% CI, 91.1%-96.7%] versus 97.4% [95% CI, 96.9%-98.0%] and 98.1% [95% CI, 96.9%-99.4%], respectively). Fixation method was not associated with mortality.

CONCLUSIONS

Cementless fixation was associated with an increased risk of revision and did not provide any benefit in terms of lower mortality in octogenarian patients.

LEVEL OF EVIDENCE

Level II, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Transversus abdominis plane infiltration for laparoscopic gastric banding: A pilot study

AIM: To estimate an effect size for the transversus abdominis plane (TAP) infiltration on quality of recovery in patients undergoing laparoscopic gastric band surgery.

METHODS: The pilot study was a randomized, double blinded, placebo controlled trial. Patients undergoing laparoscopic gastric band surgery were randomized to receive a bilateral TAP infiltration with 20 mL of 0.5% ropivacaine or saline. The evaluated outcomes included quality of recovery-40 (QoR-40) at 24 h, postoperative opioid consumption and pain. Data was examined using the Mann-Whitney U test.

RESULTS: Nineteen subjects were recruited. There was a positive trend favoring the TAP infiltration group in global QoR-40 scores at 24 h after surgery, median [interquartile range (IQR)] of 175.5 (170-189) compared to 170 (160-175) in the control group (P = 0.06). There also a positive trend toward a lower cumulative opioid consumption in the TAP infiltration group, median (IQR) of 7.5 (2.5-11.5) mg iv morphine equivalents compared to 13 (7-21.5) in the control group (P = 0.07). Correlation analysis (Spearman’s Rho) demonstrated an inverse relationship between 24 h cumulative opioid consumption and global QoR-40 scores, -0.49 (P = 0.03).

CONCLUSION: The use of multimodal analgesic techniques to reduce opioid related side effects is particularly desirable in morbidly obese patients undergoing gastric reduction surgery. The TAP infiltration seems to have a clinically important effect in reducing postoperative opioid consumption and improve quality of recovery after laparoscopic gastric band surgery in morbid obese patients. Future studies to confirm the beneficial effects of the TAP infiltration in these patients are warranted.