Fewer Wrong-Site Peripheral Nerve Blocks Following Updates to Anesthesia Time-Out Policy.

Background: Peripheral nerve block (PNB) has been shown to be safe and effective, and its use has continued to increase, but it is not without risks. One potentially preventable risk is wrong-site blocks (WSBs). Our institution mandated a time-out process before PNB in 2003, and then in 2007 made two more changes to our policy to mitigate risk: (1) the circulating/block nurse was the only person permitted to access the block needles; after a time-out period was complete, the nurse gave the needles to the anesthesiologist; and (2) the nurse remained at the patient's bedside until the PNB was initiated. Purpose: We sought to compare the incidence of WSBs before and after this time-out process was implemented in 2003 and the enhanced form of it was implemented in 2007. We hypothesized that the enhanced process would decrease the incidence of WSBs. Methods: We retrospectively analyzed data, from January 2003 to December 2016, taken from the quality assurance and performance improvement (QA/PI) division of the anesthesiology department at our institution, which maintained daily statistics on anesthetic types using quality audits from paper or electronic anesthesia records. All WSBs from this period were reported to the QA/PI division and root cause analyses performed. The incidence of WSB was compared pre- and post-implementation of the enhanced time-out policy for upper extremity, lower extremity, and all blocks by calculating relative risks with 95% score confidence intervals and performing Fisher's exact tests. Results: The incidence of WSBs decreased from 1.10/10,000 before changes to the policy were initiated to 0.24/10,000 afterward. Conclusion: We observed an association between the implementation of a dynamic, team-focused time-out process and a reduction in the incidence of WSBs at our institution. A causal effect of the enhanced time-out cannot be determined given the risk of bias associated with before-after study designs and our lack of adjustment for potential confounders. Further research is therefore warranted.

Development of a Communications Program to Support Care of Critically Ill Coronavirus Disease 2019 (COVID-19) Patients.

A significant role of intensive care unit (ICU) workforce is ongoing communication with and support for families of critically ill patients. The COVID-19 pandemic has created unanticipated challenges to this essential function. Restrictions on visitors to hospitals and unprecedented clinical demands hamper traditional communication between ICU staff and patient families. In response to this challenge, we created a dedicated communications service to provide comprehensive support to families of COVID-19 patients, and to create capacity for our ICU teams to focus on patient care. In this brief report, we describe the development, implementation, and preliminary experience with the service.

Perioperative Nonsteroidal Anti-Inflammatory Agents in the COVID-19 Orthopedic Patient.

BACKGROUND: SARS-CoV-2 infection can cause serious complications beyond lung injury and respiratory failure, including sepsis, cardiovascular injury, renal failure, coagulation abnormalities, and neurologic injury. Widely used medications such as nonsteroidal anti-inflammatory drugs (NSAIDs) have been flagged as having the potential to cause harm in the context of COVID-19. It is unknown if the benefits of NSAID use in the orthopedic population will outweigh the potential risks of increased morbidity in COVID-19 orthopedic patients. METHODS: We conducted a narrative review of the use of NSAIDs in the orthopedic patient with COVID-19, focusing on the effects of NSAIDs on the inflammatory process, the role of NSAIDs in orthopedics, and the associations between NSAID use and complications of pneumonia. RESULTS: We found that it may be appropriate to consider NSAID use in otherwise healthy orthopedic patients with COVID-19 and significant pain. CONCLUSIONS: In this context, we recommend that NSAIDs be used at the lowest effective dose for the shortest duration possible in orthopedic patients with COVID-19. However, pending further data and based on the concerns outlined in this review, we recommend avoiding NSAIDs in orthopedic patients with significant comorbidities and those who are undergoing major orthopedic surgery.

Thirty-five Years of Acute Pain Services: Where Do We Go From Here?

Acute pain services (APS) have developed over the past 35 years. Originally implemented solely to care for patients with regional catheters or patient-controlled analgesia after surgery, APS have become providers of care throughout the perioperative period, with some institutions even taking the additional step toward providing outpatient services for patients with acute pain. Models vary considerably in terms of tasks and responsibilities, staffing, education, protocols, quality, and financing. Many challenges face today's APS, including the increasing number of patients with preexisting chronic pain, intake of analgesics and opioids before surgery, substance-dependent patients needing special care, shorter hospital stays, early discharge of patients in need of further analgesic treatment, prevention and treatment of chronic postsurgical pain, minimization of adverse events, and side effects of treatment. However, many APS lack a clear-cut definition of their structures, tasks, and quality. Development of APS in the future will require us to face urgent questions, such as, "What are meaningful outcome variables?" and, "How do we define high quality?" It is obvious that focusing exclusively on pain scores does not reflect the complexity of pain and recovery. A broader approach is needed-a common concept of surgical and anesthesiological services within a hospital (eg, procedure-specific patient pathways as indicated by the programs "enhanced recovery after surgery" or the "perioperative surgical home"), with patient-reported outcome measures as one central quality criterion. Pain-related functional impairment, treatment-induced side effects, speed of mobilization, as well as return to normal function and everyday activities are key.

Trends in Ambulatory Laminectomy in the USA and Key Factors Associated with Successful Same-Day Discharge: A Retrospective Cohort Study.

BACKGROUND: Laminectomy is commonly used in the treatment of lumbar spine pathology. Laminectomies are increasingly being performed in outpatient settings, but patient safety concerns remain. QUESTIONS/PURPOSES: We aimed to describe trends in outpatient lumbar laminectomy between 2008 and 2016 and to identify factors associated with successful same-day discharge. METHODS: We identified patients who underwent single-level lumbar laminectomy between 2008 and 2016 in the American College of Surgeons' National Surgical Quality Improvement Program database and divided them into two groups according to their admission status, either inpatient or outpatient. Inpatient and outpatient groups were further divided according to actual length of stay (LOS): did not remain in the hospital overnight (LOS = 0) or stayed in the hospital overnight or longer (LOS ≥ 1). We then analyzed patient characteristics and complications for significance and to identify factors associated with successful same-day discharge. RESULTS: We identified 85,769 patients, 41,149 classified as outpatient status and 44,620 as inpatient status. Between 2008 and 2016, the proportion of procedures performed on an outpatient basis increased from 24.1 to 56.74%. Overall, 27.3% of all patients were discharged on the day of surgery, representing 52.8% of outpatients and 3.8% of inpatients. Older age and longer duration of surgery predicted that patients were less likely to have same-day discharge. Patients with a primary diagnosis other than intervertebral disk disorder, Hispanic ethnic background, or an American Society of Anesthesiologists physical status classification of III were less likely to achieve same-day discharge. Patients under the care of orthopedic surgeons (as opposed to neurosurgeons) were more likely to be discharged on the day of surgery. We also found an association between sex and day of discharge, with female patients being less likely to be discharged on the day of surgery. CONCLUSIONS: Laminectomy is increasingly being performed in the outpatient setting. Younger, healthier non-Hispanic male patients undergoing uncomplicated surgery have a higher likelihood of successful same-day discharge.

A comparison of two different concentrations and infusion rates of ropivacaine in perineural infusion administered at the same total dose for analgesia after foot and ankle surgery: a randomized, double blinded, controlled study.

BACKGROUND: Continuous popliteal nerve block is utilized for postoperative analgesia after foot and ankle surgery. Whether only the total dose of local anesthetic or the combination of concentration and volume determine the characteristics of a continuous popliteal nerve infusion remains currently unknown. We hypothesized a reduction of the incidence of insensate extremity in patients given ropivacaine 0.4% at 4 mL/h compared to patients given ropivacaine 0.2% at 8 mL/h. METHODS: Sixty-four patients scheduled for major foot and ankle surgery requiring a continuous popliteal catheter infusion for postoperative analgesia were studied. Thirty-three patients were randomized to receive a continuous popliteal nerve block with 0.2% (basal 8 mL/h) and thirty-one with 0.4% (basal 4 mL/h) ropivacaine, reaching the same total dose (16 mg/h). The primary outcome was the incidence of persistent sensory block in the distal sciatic nerve distributions in the postoperative period. Secondary outcomes were the incidence of motor block, NRS pain scores at rest in the postoperative period up to 48 hours after surgery, opioid use and related side effects, patients' satisfaction. RESULTS: The incidence of persistent sensory block was similar in patients given 0.2% and in patients receiving 0.4% ropivacaine. The incidence of motor block, postoperative pain scores at rest, use of oral opioids, side effects and patients' satisfaction with the quality of recovery were also similar in both groups. CONCLUSIONS: Our results suggest that local anesthetic total dose is the primary determinant of continuous popliteal perineural infusion effects.

Charles Burstein, MD: First Director of Anesthesiology at Hospital for Special Surgery.

Charles L. Burstein was the first departmental Director and Chief of Anesthesiology at the Hospital for Special Surgery in New York City. He joined the staff in 1937, when the hospital was still known by its original name of the Hospital for the Ruptured and Crippled. In 1940, it was renamed The Hospital for Special Surgery. Burstein, an early disciple of Emery Rovenstine, accomplished much to advance the Department of Anesthesiology through academic collaborations, education, clinical specialization, and research. He laid the groundwork for the future success of a department that continues to thrive to this day in clinical and academic orthopedic anesthesia.

Clinical Indicators of the Need for Telemetry Postoperative Monitoring in Patients With Suspected Obstructive Sleep Apnea Undergoing Total Knee Arthroplasty.

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea is associated with increased complication rates postoperatively. Current literature does not provide adequate guidance on management of these patients. This study used the STOP-Bang questionnaire to diagnose patients with possible obstructive sleep apnea (score ≥3). We hypothesized that a STOP-Bang score of 3 or greater would significantly correlate with the number of oxygen desaturation episodes during the first 48 hours after total knee arthroscopy. METHODS: The STOP-Bang questionnaire was administered to 110 patients preoperatively. All patients underwent spinal-epidural anesthesia with a saphenous nerve block and sedation and were connected to the Nellcor OxiMax N-600x pulse oximeter for 48 hours postoperatively. RESULTS: Final analysis included 98 patients. There was no significant difference in the total number of desaturation events between STOP-Bang groups (score <3 vs ≥3 and score <5 vs ≥5). The total number of desaturation events on postoperative day 1 was greater than that on day 0 (32.8 ± 42.7 vs 4.1 ± 10.0, P < 0.0001). The total number of desaturation events correlated with length of hospital stay (r = 0.329, P = 0.0001). Patients with a preoperative serum CO2 of 30 mmol/L or greater had significantly longer episodes of desaturation on postoperative day 0 compared with CO2 of less than 30 mmol/L (233.7 ± 410.1 vs 82.0 ± 126.2 seconds, P = 0.044). CONCLUSIONS: A high preoperative value of CO2 should be a warning for possible prolonged episodes of desaturation postoperatively. An attempt to limit postoperative desaturation events should be made to minimize length of stay.

An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery.

Orthopedic surgery is associated with significant perioperative pain. Providing adequate analgesia is a critical component of patient care and opioids play a vital role in the acute postoperative setting. However, opioid prescribing for patients undergoing orthopedic procedures has recently been identified as a major contributor to the current opioid epidemic. As opioid usage and related morbidity and mortality continue to rise nationwide, opioid-prescribing practices are under increased scrutiny. Here, we update the evidence base and recommendations behind a set of interventions developed at the Hospital for Special Surgery to address the national epidemic at the local level. The main components of our program include (1) guidelines for managing patients who are opioid tolerant and/or have a substance abuse disorder; (2) education programs for patients, emphasizing the role of opioids in recovery after elective orthopedic surgery; (3) education programs for prescribers of controlled substances, including clinical and regulatory aspects; (4) the development of surgery-specific prescribing recommendations for opioid-naive patients; and (5) mechanisms to modify prescribing habits to limit unnecessary prescribing of controlled substances.

Epinephrine-induced pulmonary edema during hip arthroscopy: a report of two cases and a review of the literature.

OBJECTIVES: Hip arthroscopy utilization has significantly increased in recent years. While it is a relatively safe procedure, it is not without risk. Life-threatening complications, albeit rare, can potentially occur and must be appropriately recognized and treated. We describe 2 cases in which patients' undergoing hip arthroscopy developed pulmonary edema and their respective courses of treatment. METHODS: Both patients were being treated for symptomatic femoroacetabular impingement (FAI), with labral tears, requiring operative management after a failed trial of conservative management. The complication occurred during a primary hip arthroscopy procedure and a retrospective review of their clinical records and intra-operative notes was performed. RESULTS: Hip arthroscopy was performed under spinal anesthetic in the supine position in both patients. In both procedures, patients developed severe hypertension and tachycardia, with subsequent oxygen desaturations with noted pulmonary edema. The postulated etiology was systemic effects from intra-articular epinephrine, causing acute pulmonary edema with corresponding cardiovascular changes. With supportive ventilation, selective alpha-adrenergic blocker and furosemide administration, and cessation of epinephrine exposure, vital signs normalized and both patients experienced symptom resolution. CONCLUSION: During arthroscopy, if acute hypertension, tachycardia and hypoxia develop, epinephrine-induced pulmonary edema should be considered as a cause by the treating orthopedic surgeon and anesthesiologist in order to initiate an appropriate treatment plan.

Perineural dexamethasone with subsartorial saphenous nerve blocks in ACL reconstruction.

PURPOSE: Subsartorial saphenous nerve blockade (SSNB) is an effective analgesic alternative to femoral nerve blockade after anterior cruciate ligament (ACL) reconstruction with bone-tendon-bone (BTB) autograft. It was hypothesized that dexamethasone in a SSNB will prolong analgesia, improve pain and satisfaction, and reduce postoperative opioid requirements and side effects. METHODS: One hundred ninety-five patients undergoing ACL reconstruction with BTB autograft (ages 16-65) were enrolled. Subjects received SSNB with 13 ml of 0.5 % bupivacaine (control group), 1 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group I), or 4 mg preservative-free dexamethasone +0.5 % bupivacaine (treatment group II). Subjects received identical perioperative management. On postoperative days 1 and 2, subjects reported perceived block duration, pain scores, satisfaction, opioid use, and side effects. Cox-proportional hazards modelling was used to compare block duration, adjusting for body mass index, age, sex, tourniquet time, American Society of Anesthesiologists classification, and intravenous dexamethasone dose. RESULTS: Patient-perceived block duration was significantly increased in treatment group I [hazard ratio (95 % confidence interval [CI]) 0.48 (0.31-0.75); P = 0.001] and treatment group II (hazard ratio (95 % CI): 0.52 (0.33-0.81); P = 0.004) compared to control. The block was extended from a median (95 % CI) of 33.1 (28.4-37.3) to 41.2 (32.4-50.9) and 46.5 (35.8-48.9) hours, respectively. Additionally, patients in treatment group II reported increased time that block provided pain relief, higher patient satisfaction, lower pain scores at rest, and decreased drowsiness and confusion. CONCLUSION: The addition of 1 and 4 mg of dexamethasone to the block injectate significantly increased SSNB duration by 8-13 h compared to control. LEVEL OF EVIDENCE: Therapeutic study, level 1.

The training and careers of regional anesthesiology and acute pain medicine fellows, 2013.

BACKGROUND AND OBJECTIVES: Fellowships in regional anesthesiology and acute pain medicine (RAAPM) have grown exponentially during the past decade, both in terms of total programs and fellows trained. This survey-based study reports fellowship graduates' assessment of the strengths and weaknesses of their training and how the fellowship has affected their careers. METHODS: Graduates of North American RAAPM fellowships were asked to participate in a 16-question survey designed to describe their training and subsequent career. Academic anesthesiology department chairs were simultaneously surveyed to determine how the RAAPM components of their residency training programs are staffed and organized. RESULTS: Graduate and department chair response rates were 59% and 44%, respectively. During the past decade, significant improvements have occurred in peripheral nerve block, perineural catheter, and acute pain medicine training. Many fellowship graduates note less robust educational experiences in research and the nontechnical aspects of the subspecialty. CONCLUSIONS: The results of this study should prove useful to fellowship directors as they refine the educational offerings of their programs.

Postoperative Analgesia with Saphenous Block Appears Equivalent to Femoral Nerve Block in ACL Reconstruction.

BACKGROUND: Adequate pain control following anterior cruciate ligament reconstruction (ACL) often requires regional nerve block. The femoral nerve block (FNB) has been traditionally employed. Ultrasound application to regional nerve blocks allows for the use of alternatives such as the saphenous nerve block following ACL reconstruction. QUESTIONS/PURPOSES: This study evaluated postoperative analgesia provided by the subsartorial saphenous nerve block (SSNB) compared to that provided by the traditional FNB for patients undergoing ACL reconstruction with patellar tendon (bone-tendon-bone (BTB)) autografts. METHODS: A randomized, blinded, controlled clinical trial was conducted using 80 ASA I-III patients, ages 16-65, undergoing ACL reconstruction with BTB. The individuals assessing all outcome measures were blinded to the treatment group. Postoperatively, all patients received cryotherapy and parenteral hydromorphone to achieve numeric rating scale pain scores less than 4. At discharge, patients were given prescriptions for oral opioid analgesics and a scheduled NSAID. Patients were instructed to complete pain diaries and record oral opioid utilization. Patients were contacted on postoperative days (POD) 1 and 2 to ascertain the level of patient satisfaction with the analgesic regimen. RESULTS: No differences between the two groups were found. Patient demographics and postoperative pain scores at rest were not different. In addition, there was no difference in opioid use, as measured in daily oral morphine equivalents between groups. A small but statistically significant report of higher patient satisfaction with the FNB was found on POD 1 but not on POD 2. CONCLUSION: These data support our hypothesis that the SSNB provides similar and adequate postoperative analgesia when compared to the FNB, following arthroscopic ACL reconstruction with patellar tendon autograft.

Anesthesiologists' familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting.

STUDY OBJECTIVE: To assess anesthesiologists' familiarity with the American Society of Anesthesiologists (ASA) and American College of Surgeons (ACS) guidelines on Advance Directives in the perioperative setting. DESIGN: Single-center, 4-question anonymous survey. SETTING: Urban academic medical center. SUBJECTS: Up to 34 subjects responded to each question. MEASUREMENTS AND MAIN RESULTS: Familiarity with the ASA and ACS guidelines on Advance Directives in the perioperative setting ranged from 45% to 100%. CONCLUSIONS: There was inadequate familiarity with components of the ASA and ACS guidelines on advance directives in the perioperative setting. Larger studies are required to assess anesthesiologists' familiarity with national society guidelines that directly affect patient care. Future work should investigate best practices for guideline implementation, and consequences of poor adherence to national guidelines.

A checklist for performing regional nerve blocks.

Regional blocks are frequently invasive procedures that create the risk of infection, local anesthetic toxicity, and wrong-site performance. National guidelines have been developed by the Joint Commission and the American Society of Regional Anesthesia and Pain Medicine (ASRA) to reduce the potential for each of these risks. Checklists have been shown to reduce errors and complications in medicine: it seems prudent to incorporate the recommended safety steps into a formalized checklist to be reviewed before performance of a regional block. A task force appointed by the ASRA President reviewed available resources and recommendations and performed a survey of RAPM members at the ASRA annual meeting in May 2013 and proposed a 9-point checklist to fulfill this role. Although it is apparent that local modification will be needed, the basic points and principles should be adopted for the performance of regional blocks.

Thomas Linwood Bennett, MD: one of New York City's first prominent physician anesthetists.

Thomas Linwood Bennett (1868-1932) was one of New York City's first prominent physician anesthetists. He was the first dedicated anesthetist at the Hospital for the Ruptured and Crippled, subsequently renamed Hospital for Special Surgery. He subsequently practiced at multiple institutions throughout New York City as one of the first physicians in the United States to dedicate his entire practice to the emerging field of anesthesia. Bennett was considered the preeminent anesthetist of his time, excelling at research, innovation, education, and clinical care.