Ultrasound-Guided Continuous Bilateral Erector Spinae Plane Blocks Are Associated with Reduced Opioid Consumption and Length of Stay for Open Cardiac Surgery: A Retrospective Cohort Study.

This study tested the hypothesis that continuous bilateral erector spinae plane blocks placed preoperatively would reduce opioid consumption and improve outcomes compared with standard practice in open cardiac surgery patients. Patients who received bilateral continuous erector spinae plane blocks for primary open coronary bypass, aortic valve, or ascending aortic surgery were compared to a historical control group. Patients in the block group received a 0.5% ropivacaine bolus preoperatively followed by a 0.2% ropivacaine infusion begun postoperatively. No other changes were made to the perioperative care protocol. The primary outcome was opioid consumption. Secondary outcomes were time to extubation and length of stay. Twenty-eight patients received continuous erector spinae plane blocks and fifty patients served as historic controls. Patients who received blocks consumed less opioids, expressed as oral morphine equivalents, both intraoperatively (34 ± 17 vs. 224 ± 125 mg) and during their hospitalization (224 ± 108 vs. 461 ± 185 mg). Patients who received blocks had shorter times to extubation (126 ± 87 vs. 257 ± 188 min) and lengths of stay in the intensive care unit (35 ± 17 vs. 58 ± 42 h) and hospital (5.6 ± 1.6 vs. 7.7 ± 4.6 days). Continuous erector spinae plane blocks placed prior to open cardiac surgical procedures reduced opioid consumption, time to extubation, and length of stay compared to a standard perioperative pathway.

Data and meta-analysis for choosing sugammadex or neostigmine for routine reversal of rocuronium block in adult patients.

This meta-analysis was conducted to define clinical efficacy and side effects (bradycardia and post-operative nausea and vomiting [PONV]) in trials comparing sugammadex with neostigmine or placebo for reversal of rocuronium-induced neuromuscular blockade in adult patients. A search of PubMed, Google Scholar, and Cochrane Library electronic databases identified 111 clinical trials for potential inclusion. We performed a meta-analysis of 32 studies that quantitatively compared the efficacy and side effects of sugammadex with either neostigmine or placebo in adult patients requiring general anesthesia. Analyzed outcomes were reversal time, anesthesia time, duration of stay in the post-anesthesia care unit (PACU), and the occurrence of bradycardia or PONV. Odds ratios and 95% confidence intervals (CI) were calculated for binary data. Mean differences and 95% CI were calculated for continuous outcome data. Meta-analyses were performed using random and fixed-effects models. Heterogeneity across studies was assessed using Cochran's Q test and the I2 statistic. Quantification of these outcomes can better inform anesthetists and health systems of the relative costs and benefits of the two reversal agents. This information also forms a basis for a comparative cost analysis in a co-submitted manuscript [1].

Sugammadex versus neostigmine for routine reversal of rocuronium block in adult patients: A cost analysis.

STUDY OBJECTIVE: This report analyzes the comparative costs, efficacy and side effects of a newer, more expensive reversal drug, sugammadex, with its generic counterpart, neostigmine combined with glycopyrrolate, or no reversal agent when used routinely to reverse rocuronium-induced neuromuscular blockade in adult patients. DESIGN: Cost analysis. METHODS: We constructed a decision model to analyze the costs associated with the choice of reversal drug and differences in reversal time, occurrence of postoperative nausea or vomiting (PONV), and residual blockade requiring unplanned postoperative mechanical ventilation (UPMV). We selected variables that demonstrated meaningful differences in meta-analyses of published studies and/or had significant associated costs. We used data from local hospital system information, meta-analysis of published studies, and the general literature to construct base-case scenarios and sensitivity analyses. We performed the analysis from the perspective of a single hospital system. Costs were in 2019 U.S. dollars. RESULTS: Cost analysis suggested that reversal with sugammadex is preferable to neostigmine or no reversal drug when operating room (OR) time was valued at ≥$8.60/min (base case $32.49/min). Net costs of sugammadex were less than no treatment or neostigmine reversal when the probability of UPMV exceeded 0.019 and 0.036, respectively. Neither sugammadex nor neostigmine reversal was preferable to no treatment in a base-case analysis that considered the effect of the reversal agent on only drug and PONV costs, disregarding costs of OR time or UPMV. CONCLUSIONS: Routine reversal with sugammadex is preferable to choosing neostigmine or no reversal drug when accounting for potential savings in OR time. Sugammadex might also be a reasonable choice for patients at high risk of UPMV. If the cost of OR time is not considered, the analysis does not support the routine use of sugammadex in patients with perceived increased risk or solely to reduce PONV.

Role of the anesthesiologist-intensivist outside the ICU: opportunity to add value for the hospital or an unnecessary distraction?

PURPOSE OF REVIEW: Given the extremely expensive nature of critical care medicine, it seems logical that intensivists should play an active role in designing efficient systems of care. The true value of intensivists, however, is not well defined. RECENT FINDINGS: Anesthesiologists have taken key roles in improving patient safety in the operating room. Anesthesia-related mortality rates have decreased from 20 deaths per 100 000 anesthetics in the early 1980s to less than one death per 100 000 currently. Anesthesiologist-intensivists remain rare (less than 5% of certified anesthesiologists), but increasingly play multiple roles within multidisciplinary teams. This review outlines the roles of intensivists in performance improvement, perioperative assessment; sedation services, extracorporeal and mechanical support, and code/rapid response teams. Critical-care physicians, by definition, work in collaborative multispecialty and multidisciplinary teams that make it difficult to isolate each team member's precise contribution to healthcare value. SUMMARY: Anesthesiologist-intensivists working outside their usual environment provide leadership and clinical guidance towards improving patient outcomes.

Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies at a University Medical Center.

BACKGROUND: Intraoperative lung-protective ventilation (ILPV) is defined as tidal volumes <8 mL/kg ideal bodyweight and is increasingly a standard of care for major abdominal surgical procedures performed under general anesthesia. In this study, we report the result of a quality improvement initiative targeted at improving adherence to ILPV guidelines in a large academic teaching hospital. METHODS: We performed a time-series study to determine whether anesthesia provider adherence to ILPV was affected by certain improvement interventions and patient ideal body weight (IBW). Tidal volume data were collected at 3 different time points for 191 abdominal surgical cases from June 2014 through April 2015. Improvement interventions during that period included education at departmental grand rounds, creation of a departmental ILPV policy, feedback of tidal volume and failure rate data at grand rounds sessions, and reducing default ventilator settings for tidal volume. Mean tidal volume per kilogram of ideal body weight (VT/kg IBW) and rates of noncompliance with ILPV were analyzed before and after the interventions. A survey was administered to assess provider attitudes after implementation of improvement interventions. Responses before and after interventions and between physician and nonphysician providers were analyzed. RESULTS: Reductions in mean VT/kg IBW and rates of failure for providers to use ILPV occurred after improvement interventions. Patients with IBW <65 kg received higher VT/kg IBW and had higher rates of failure to use ILPV than patients with IBW >65 kg. Surveyed providers demonstrated stronger agreement to having knowledge and practice consistent with ILPV after interventions. CONCLUSIONS: Our interventions improved anesthesia provider adherence to low tidal volume ILPV. IBW was found to be an important factor related to provider adherence to ILPV. Provider attitudes about their knowledge and practice consistent with ILPV also changed with our interventions.

Should Early Prone Positioning Be a Standard of Care in ARDS With Refractory Hypoxemia?

For the past 4 decades, the prone position has been employed as an occasional rescue option for patients with severe hypoxemia unresponsive to conventional measures applied in the supine orientation. Proning offers a high likelihood of significantly improved arterial oxygenation to well selected patients, but until the results of a convincing randomized trial were published, its potential to reduce mortality risk remained in serious doubt. Proning does not benefit patients of all disease severities and stages but may be life-saving for others. Because it requires advanced nursing skills and escalation of monitoring surveillance to deploy safely, its place as an early stage standard of care depends on the definition of that label.

Early Paralysis for the Management of ARDS.

The use of neuromuscular blocking agents (NMBAs) early in the development of ARDS has been a strategy of interest for many years. The use of NMBAs with a concomitant deep sedation strategy can increase oxygenation and possibly decrease mortality when used in the early stages of ARDS. The mechanism by which this occurs is unclear but probably involves a combination of factors, such as improving patient-ventilator synchrony, decreasing oxygen consumption, and decreasing the systemic inflammatory response associated with ARDS. The use of NMBA and deep sedation for these patients is not without consequence. This discussion describes the rationale and evidence behind the use of NMBAs in the setting of ARDS.

Emergency tracheal intubation: techniques and outcomes.

Performing emergency endotracheal intubation necessarily means doing so under less than ideal conditions. Rates of first-time success will be lower than endotracheal intubation performed under controlled conditions in the operating room. Some factors associated with improved success are predictable and can be modified to improve outcome. Factors to be discussed include the initial decision to perform endotracheal intubation in out-of-hospital settings, qualifications and training of providers performing intubation, the technique selected for advanced airway management, and the use of sedatives and neuromuscular blocking agents.

Cigarette smokers have reduced risk for post-dural puncture headache.

BACKGROUND:   Although headache is the most common complication of dural puncture, knowledge gaps remain about patient-related risks. Data are lacking on the role, if any, of tobacco smoking, race, anxiety, depression, and Post Traumatic Stress Disorder (PTSD) in conferring risk for post-dural puncture headache (PDPH). OBJECTIVE:   To determine the influence of tobacco smoking, race, anxiety,depressed mood, and PTSD on the risk for PDPH. STUDY DESIGN:   Retrospective chart review, single site. METHODS:   We determined the incidence of significant PDPH according to age, sex, race, smoking status, and psychiatric diagnosis in 153 consecutive research patients at the Cincinnati Veterans Affairs Medical Center who had continuous cerebrospinal fluid (CFS) sampling performed after using a large-bore (17 gauge) Tuohy needle to place a 20-gauge polyamide catheter in the lumbar spinal canal. RESULTS:   Thirty-nine subjects (25.5%) had significant PDPH, defined as requiring an epidural blood patch for therapy (an average of 4 days post-procedure).  Greater age was associated with a decreased risk of PDPH (P = 0.008); subjects over the age of 40 had the lowest incidence (15.7%). Women and men had a 31.4% and 23.7% incidence of PDPH, respectively; these were not significantly different (P = 0.38).  Neither were rates of PDPH in Caucasians (28.0%) and African-Americans (15.6%) significantly different (P = 0.18)   Healthy controls had a higher incidence of PDPH than patients with PTSD (P = 0.032).  Smokers had a lower incidence of PDPH than non-smokers, 13.7% vs. 34.1% (P = 0.009).  LIMITATIONS:   This was not a prospective study, rather a retrospective chart review.  CONCLUSION:   Most notably, smokers had a considerably reduced rate of PDPH in comparison with non-smokers.  This information could be a useful addition to the clinical assessment of relative risk for PDPH.  Further research into the mechanisms by which tobacco smoking may inhibit PDPH, such as nicotine stimulation of dopamine neurotransmission or alterations in coagulation, appears warranted.

When should sedation or neuromuscular blockade be used during mechanical ventilation?

Sedation has become an important part of critical care practice in minimizing patient discomfort and agitation during mechanical ventilation. Pain, anxiety, and delirium form a triad of factors that can lead to agitation. Achieving and maintaining an optimal level of comfort and safety in the intensive care unit plays an essential part in caring for critically ill patients. Sedatives, opioids, and neuromuscular blocking agents are commonly used in the intensive care unit. The goal of therapy should be directed toward a specific indication, not simply to provide restraint. Standard rating scales and unit-based guidelines facilitate the proper use of sedation and neuromuscular blocking agents. The goal of sedation is a calm, comfortable patient who can easily be aroused and who can tolerate mechanical ventilation and procedures required for their care.