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Karimi H, Patel J, Olmos M, Kanter M, Hernandez NS, Silver RE, Liu P, Riesenburger RI, Kryzanski J. Spinal Anesthesia Reduces Perioperative Polypharmacy and Opioid Burden in Patients Over 65 Who Undergo Transforaminal Lumbar Interbody Fusion. World Neurosurg 2024; 185:e758-e766. [PMID: 38432509 DOI: 10.1016/j.wneu.2024.02.127] [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: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Polypharmacy and opioid administration are thought to increase the risk of postoperative cognitive dysfunction and delirium in elderly patients. Spinal anesthesia (SA) holds potential to reduce perioperative polypharmacy in spine surgery. As more geriatric patients undergo spine surgery, understanding how SA can reduce polypharmacy and opioid administration is warranted. We aim to compare the perioperative polypharmacy and dose of administered opioids in patients ≥65 years who undergo transforaminal lumbar interbody fusion (TLIF) under SA versus general anesthesia (GA). METHODS A retrospective analysis of 200 patients receiving a single-surgeon TLIF procedure at a single academic center (2014-2021) was performed. Patients underwent the procedure with SA (n = 120) or GA (n = 80). Demographic, procedural, and medication data were extracted from the medical record. Opioid consumption was quantified as morphine milligram equivalents (MME). Statistical analyses included χ2 or Student's t-test. RESULTS Patients receiving SA were administered 7.45 medications on average versus 12.7 for GA patients (P < 0.001). Average perioperative opioid consumption was 5.17 MME and 20.2 MME in SA and GA patients, respectively (P < 0.001). The number of patients receiving antiemetics and opioids remained comparable postoperatively, with a mean of 32.2 MME in the GA group versus 27.5 MME in the SA group (P = 0.14). Antiemetics were administered less often as a prophylactic in the SA group (32%) versus 86% in the GA group (P < 0.001). CONCLUSIONS SA reduces perioperative polypharmacy in patients ≥65 years undergoing TLIF procedures. Further research is necessary to determine if this reduction correlates to a decrease the incidence of postoperative cognitive dysfunction and delirium.
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Affiliation(s)
- Helen Karimi
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA.
| | - Jainith Patel
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Michelle Olmos
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Matthew Kanter
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nicholas S Hernandez
- Department of Neurosurgery, University of California San Diego, La Jolla, California, USA
| | - Rachel E Silver
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts, USA; Energy Metabolism Research Laboratory, Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA
| | - Penny Liu
- Department of Anesthesiology, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ron I Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
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Medhat MM, Kamel AAF, Salem DAE, Alagamy SA, Fathi HM. 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. Anesth Pain Med 2023; 13:e138623. [PMID: 38028113 PMCID: PMC10664163 DOI: 10.5812/aapm-138623] [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: 06/26/2023] [Revised: 07/21/2023] [Accepted: 07/28/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Marwa Mohamed Medhat
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
| | - Alshaimaa Abdel Fattah Kamel
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
| | | | - Sherif A. Alagamy
- Department of orthopedic, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
| | - Heba M Fathi
- Department of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Zagazig University, Alsharkia, Egypt
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Gupta S, Rane A. Enhanced Recovery after Surgery: Perspective in Elder Women. J Midlife Health 2021; 12:93-98. [PMID: 34526741 PMCID: PMC8409712 DOI: 10.4103/jmh.jmh_89_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/19/2021] [Accepted: 06/28/2021] [Indexed: 11/04/2022] Open
Abstract
Enhanced recovery after surgery (ERAS) is a multimodal convention first reported for colorectal and gynecologic procedures. The main benefits have been a shorter length of stay and reduced complications, leading to improved clinical outcomes and cost savings substantially. With increase in life expectancy, recent years has shown a significant rise in advanced age population, and similarly, a rise in age-related disorders requiring surgical management. Due to pathophysiological and metabolic changes in geriatric age group with increased incidence of medical comorbidities, there is higher risk of enhanced surgical stress response with undesirable postoperative morbidity, complications, prolonged immobility, and extended convalescence. The feasibility and effectiveness of ERAS protocols have been well researched and documented among all age groups, including the geriatric high-risk population.[1] Adhering to ERAS protocols after colorectal surgery showed no significant difference in postoperative complications, hospital stay, or readmission rate among various age groups.[2] A recent report mentions the safety and benefits following ERAS guidelines with reduced length of stay in elderly patients with short-level lumbar fusion surgery.[3] The concept of prehabilitation has evolved as an integral part of ERAS to build up physiological reserve, especially in geriatric high-risk group, and to adapt better to surgical stress.[4] High levels of compliance with ERAS interventions combined with prehabilitation can be achieved when a dedicated multidisciplinary team is involved in care of these high-risk patients.
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Affiliation(s)
- Sandhya Gupta
- Department of Obstetrics and Gynaecology, James Cook University, Townsville, Australia
| | - Ajay Rane
- Department of Obstetrics and Gynaecology, James Cook University, Townsville, Australia
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Gupta R, Arora D, Kaur S, Kaur B, Kaur S. Comparative study of hemodynamic effects of intrathecal bupivacaine with butorphanol in cardiac and non-cardiac patients. J Anaesthesiol Clin Pharmacol 2021; 36:511-517. [PMID: 33840933 PMCID: PMC8022051 DOI: 10.4103/joacp.joacp_70_20] [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: 03/04/2020] [Revised: 05/03/2020] [Accepted: 07/20/2020] [Indexed: 11/14/2022] Open
Abstract
Background and Aims: The synergism between intrathecal opioids and low dose local anesthetics makes it possible to achieve reliable spinal anesthesia (SA) with minimal hypotension. The study objective was to compare the hemodynamic effects of reduced dose of 0.5% intrathecal bupivacaine (2mL) with 25 μg butorphanol in cardiac vs non-cardiac patients. Material and Methods: We included sixty patients aged 30-80 years, undergoing infraumbilical surgeries in the study and compared thirty cardiac patients with mild to moderate reduction in left ventricular ejection fraction (LVEF) on 2D echocardiography (Group C) with 30 non-cardiac patients (Group NC) for similar types of surgery. Both the groups received 0.5% bupivacaine 2.0 ml with 25 μg butorphanol. Results: The spinal block characteristics were similar in both groups (P > 0.05). The blood pressure of the patients in the two groups was comparable till 80 min P > 0.05 after which Group NC had significant increase in blood pressure compared to Group C upto 95 min (P < 0.05). Similarly, heart rate was comparable until 90 min (P > 0.05) after which Group NC had significant increase in heart rate versus Group C upto 100 min (P < 0.05). Eight patients in group C and five patients in group NC showed hypotension. Bradycardia was seen in 4 patients in group C in comparison to only one patient in group NC. Conclusion: We can safely consider spinal anesthesia with 10 mg bupivacaine and 25μg butorphanol in cardiac patients with mild to moderately reduced ejection fraction presenting for infraumbilical non-cardiac surgeries with the advantage of intraoperative hemodynamic stability and adequate postoperative analgesia.
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Affiliation(s)
- Ruchi Gupta
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Deepika Arora
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Shubhdeep Kaur
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Balpreet Kaur
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
| | - Sukhvir Kaur
- Department of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences and Research, Amritsar, Punjab, India
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Ashoor TM, Hussien NS, Anis SG, Esmat IM. Dexamethasone blunts postspinal hypotension in geriatric patients undergoing orthopedic surgery: a double blind, placebo-controlled study. BMC Anesthesiol 2021; 21:11. [PMID: 33430772 PMCID: PMC7798187 DOI: 10.1186/s12871-021-01232-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 01/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Post-spinal anesthesia (PSA) hypotension in elderly patients is challenging. Correction of PSA hypotension by fluids either colloids or crystalloids or by vasoconstrictors pose the risk of volume overload or compromising cardiac conditions. Dexamethasone is used to treat conditions manifested by decrease of peripheral vascular resistance. The research team was the first to test the hypothesis of its role in preventing or decreasing the incidence of PSA hypotension. METHODS One hundred ten patients, aged 60 years or more were recruited to receive a single preoperative dose of dexamethasone 8 mg IVI in 100 ml normal saline (D group) (55 patients) 2 h preoperatively, and 55 patients were given placebo (C group) in a randomized, double-blind trial. Variations in blood pressure and heart rate in addition to the needs of ephedrine and/or atropine following spinal anesthesia (SA) were recorded. SA was achieved using subarachnoid injection of 3 ml hyperbaric bupivacaine 0.5%. RESULTS Demographic data and the quality of sensory and motor block were comparable between groups. At 5th, 10th minutes post SA; systolic, diastolic and mean arterial pressures were statistically significant higher in D group. At 20th minutes post SA; the obtained blood pressure readings and heart rate changes didn't show any statistically significance between groups. The need for ephedrine and side effects were statistically significant lower in D group than C group. CONCLUSION Post-spinal anesthesia hypotension, nausea, vomiting and shivering in elderly patients were less common after receiving a single preoperative dose of dexamethasone 8 mg IVI than control. REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT03664037 , Registered 17 September 2018 - Retrospectively registered, http://www.ClinicalTrial.gov.
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Affiliation(s)
- Tarek M Ashoor
- Department of Anesthesia and Intensive Care, Ain Shams University, Cairo, Egypt.
| | - Noha S Hussien
- Department of Anesthesia and Intensive Care, Faculty of Medicin, Ain Shamse University, Cairo, Egypt
| | - Sherif G Anis
- Department of Anesthesia and Intensive Care, Faculty of Medicin, Ain Shamse University, Cairo, Egypt
| | - Ibrahim M Esmat
- Department of Anesthesia and Intensive Care, Faculty of Medicin, Ain Shamse University, Cairo, Egypt
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Chaturvedi R, Burton BN, Gabriel RA. Complication Rates and the Benefits of Neuraxial Anesthesia in the Patient With High Comorbidity Burden Undergoing Primary Total Joint Arthroplasty. J Arthroplasty 2020; 35:3089-3092. [PMID: 32636107 DOI: 10.1016/j.arth.2020.06.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/03/2020] [Accepted: 06/08/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The American Society of Anesthesiologists physical status classification 4 (ASA PS 4) comprises patients with "severe systemic disease that is a constant threat to life." The purpose of this study is to conduct a retrospective analysis to report the rate of complications in the ASA PS 4 patients who undergo elective total joint arthroplasty (TJA). In addition, we report whether neuraxial anesthesia is associated with improved outcomes compared to general anesthesia in these patients. METHODS The American College of Surgeons National Surgical Quality Improvement Program registry was used to extract patient records. The study population included patients aged ≥18 years who underwent TJA from 2014 to 2016 and who were classified as ASA PS 4. To measure differences in outcomes and patient characteristics, we used chi-squared tests. Odds ratios (ORs) and their 95% confidence intervals (CIs) were reported for all covariates. A P value of <.01 was selected. RESULTS Among the patients who were ASA PS 4, 58 (1.4%) experienced 30-day mortality, 349 (8.2%) experienced 30-day readmission, 271 (6.3%) had a postoperative complication, and 504 (11.8%) required a transfusion. Those receiving neuraxial anesthesia compared to general anesthesia had lower odds of 30-day mortality (OR, 0.24; 95% CI, 0.12-0.49; P = .0001) and lower odds of perioperative transfusion (OR, 0.53; 95% CI 0.45-0.65; P < .0001). CONCLUSION The elevated risks for ASA PS 4 patients undergoing TJA may be too high to justify surgery. Neuraxial anesthesia is a reasonable alternative to general anesthesia if pursuing TJA in patients with a very high comorbidity burden.
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Affiliation(s)
- Rahul Chaturvedi
- Department of Anesthesiology, School of Medicine, University of California, San Diego, La Jolla, CA
| | - Brittany N Burton
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA
| | - Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA; Division of Biomedical Informatics, University of California, San Diego, La Jolla, CA
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