Sub-chondroplasty Reduces Pain, Improves Function and Delays the Conversion to Arthroplasty in Patients with Advanced Knee Osteoarthritis: A Stratified Meta-analysis and Quality Assessment.

There is an ongoing interest in alternatives to total knee arthroplasty, as a means to delay inevitable replacement. A possible, minimally invasive, alternative is a sub-chondroplasty, involving interosseous injection of bone substitute materials such as calcium phosphate (CaPo4), platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) or Injectable demineralized bone matrix (iDBM) into the subchondral bone. Eleven clinical trials were found, investigating the effectiveness of sub-chondroplasties performed using CaPo4, PRP, BMAC, and iDBM. A non-stratified and stratified meta-analysis of the included studies were conducted to test for confounding variables across the trials. Non-stratified analysis, regardless of injectable type, revealed a significant improvement in the average Visual Analog Scale (VAS) score and postoperative Knee Injury and Osteoarthritis Outcome Score (KOOS) in patients post sub-chondroplasty, as compared to baseline. This analysis demonstrates that the sub-chondroplasty procedure reduces pain, improves function, and has lower risk of conversion to arthroplasty. (Journal of Surgical Orthopaedic Advances 32(2):065-074, 2023).

Pain and Opioid Consumption and Mobilization after Surgery: Post Hoc Analysis of Two Randomized Trials.

BACKGROUND: Early mobilization is incorporated into many enhanced recovery pathways. Inadequate analgesia or excessive opioids may restrict postoperative mobilization. The authors tested the hypotheses that in adults recovering from abdominal surgery, postoperative pain and opioid consumption are inversely related to postoperative mobilization, and that postoperative mobilization is associated with fewer potentially related complications. METHODS: The authors conducted a subanalysis of two trials that enrolled adults recovering from abdominal surgery. Posture and movement were continuously monitored for 48 postoperative hours using noninvasive untethered monitors. Mobilization was defined as the fraction of monitored time spent sitting or standing. RESULTS: A total of 673 patients spent a median [interquartile range] of 7% [3 to 13%] of monitored time sitting or standing. Mobilization time was 1.9 [1.0 to 3.6] h/day for patients with average pain scores 3 or lower, but only 1.2 [0.5 to 2.6] h/day in those with average scores 6 or greater. Each unit increase in average pain score was associated with a decrease in mobilization time of 0.12 (97.5% CI, 0.02 to 0.24; P = 0.009) h/day. In contrast, there was no association between postoperative opioid consumption and mobilization time. The incidence of the composite of postoperative complications was 6.0% (10 of 168) in the lower mobilization quartile, 4.2% (7 of 168) in the second quartile, and 0% among 337 patients in the highest two quartiles (P = 0.009). CONCLUSIONS: Patients recovering from abdominal surgery spent only 7% of their time mobilized, which is considerably less than recommended. Lower pain scores are associated with increased mobility, independently of opioid consumption. Complications were more common in patients who mobilized poorly.

A Comparison of Neuraxial and General Anesthesia for Thirty-Day Postoperative Outcomes in United States Veterans Undergoing Total Knee Arthroplasty.

BACKGROUND: The aim of this study is to investigate which anesthetic technique is superior on 30-day outcomes after primary total knee arthroplasty (TKA) in United States veteran patients. To our knowledge, this is the first account from the Veterans Health Administration comparing the effects of different anesthesia modalities in patients undergoing TKA. METHODS: The Veterans Affairs Surgical Quality Improvement Program database was utilized to analyze patients undergoing primary TKA during the period of 2008-2015. Subjects were divided into 2 cohorts based on the method of surgical anesthesia used: general anesthesia or neuraxial anesthesia. Propensity score matching was utilized to avoid possible selection bias between the 2 cohorts when assessing patient demographics and comorbidities. The 2 groups were analyzed for 30-day postoperative complications, using multivariable logistic regression techniques to evaluate independent associations between anesthetic method and postoperative outcomes. RESULTS: All Veterans Affairs patients undergoing primary TKA under general anesthesia (n = 32,363) and neuraxial anesthesia (n = 14,395) within the study period were included in this study. Following propensity score matching, multivariable analysis revealed significantly lower risks of cardiovascular (adjusted odds ratio [AOR] 0.74, 95% confidence interval [CI] 0.6-0.88, P < .001), respiratory (AOR 0.75, 95% CI 0.57-0.97, P = .03), and renal complications (AOR 0.62, 95% CI 0.4-0.9, P = .01) in patients receiving neuraxial anesthesia compared to those receiving general anesthesia. Neuraxial anesthesia was also associated with reduced hospital stay and lower odds of prolonged hospitalization (AOR 0.85, 95% CI 0.8-0.9, P < .001). CONCLUSION: Veteran patients undergoing TKA under neuraxial anesthesia had reduced postoperative complications and decreased hospitalization stay compared to patients undergoing general anesthesia.

Effect of Intravenous Acetaminophen on Postoperative Hypoxemia After Abdominal Surgery: The FACTOR Randomized Clinical Trial.

Importance: Opioid-induced ventilatory depression and hypoxemia is common, severe, and often unrecognized in postoperative patients. To the extent that nonopioid analgesics reduce opioid consumption, they may decrease postoperative hypoxemia. Objective: To test the hypothesis that duration of hypoxemia is less in patients given intravenous acetaminophen than those given placebo. Design, Setting, and Participants: Randomized, placebo-controlled, double-blind trial conducted at 2 US academic hospitals among 570 patients who were undergoing abdominal surgery, enrolled from February 2015 through October 2018 and followed up until February 2019. Interventions: Participants were randomized to receive either intravenous acetaminophen, 1 g (n = 289), or normal saline placebo (n = 291) starting at the beginning of surgery and repeated every 6 hours until 48 postoperative hours or hospital discharge, whichever occurred first. Main Outcomes and Measures: The primary outcome was the total duration of hypoxemia (hemoglobin oxygen saturation [Spo2] <90%) per hour, with oxygen saturation measured continuously for 48 postoperative hours. Secondary outcomes were postoperative opioid consumption, pain (0- 10-point scale; 0: no pain; 10: the most pain imaginable), nausea and vomiting, sedation, minimal alveolar concentration of volatile anesthetic, fatigue, active time, and respiratory function. Results: Among 580 patients randomized (mean age, 49 years; 48% women), 570 (98%) completed the trial. The primary outcome, median duration with Spo2 of less than 90%, was 0.7 (interquartile range [IQR], 0.1-5.1) minutes per hour among patients in the acetaminophen group and 1.1 (IQR, 0.1-6.6) minutes per hour among patients in the placebo group (P = .29), with an estimated median difference of -0.04 (95% CI,-0.18 to 0.11) minutes per hour. None of the 8 secondary end points differed significantly between the acetaminophen and placebo groups. Mean pain scores within initial 48 postoperative hours were 4.2 (SD, 1.8) in the acetaminophen group and 4.4 (SD, 1.8) in the placebo group (difference, -0.28; 95% CI, -0.71 to 0.15); median opioid use in morphine equivalents was 50 mg (IQR, 18-122 mg) and 58 mg (IQR, 24-151 mg) , respectively, with a ratio of geometric means of 0.86 (95% CI, 0.61-1.21). Conclusions and Relevance: Among patients who underwent abdominal surgery, use of postoperative intravenous acetaminophen, compared with placebo, did not significantly reduce the duration of postoperative hypoxemia over 48 hours. The study findings do not support the use of intravenous acetaminophen for this purpose. Trial Registration: ClinicalTrials.gov Identifier: NCT02156154.

The use of extended release bupivacaine with transversus abdominis plane and subcostal anterior quadratus lumborum catheters: A retrospective analysis of a novel technique.

BACKGROUND AND AIMS: Liposomal bupivacaine (LB) is a formulation of local anesthetic that may exert analgesia over a prolonged period. Anecdotal use of LB suggests benefit and prolonged analgesia when used to supplement infiltration blocks. Our aim was to test the effect of a bolus of LB delivered through a nerve catheter in two types of interfascial plane blocks (transversus abdominis plane and anterior subcostal quadratus lumborum). The effect was evaluated through patient self-reporting of postsurgical pain up to 48 postoperative hours. MATERIAL AND METHODS: Medical records of adult postoperative patients who received LB in a peripheral nerve catheter were followed retrospectively and analysed for pain scores and spread of dermatomal numbness over 48 h following the postoperative dose. A chart review of patients who qualified between June 2015 and March 2017 was performed, and clinical data were obtained from the institutional Perioperative Health Documentation System. RESULTS: Pain scores decreased following LB bolus, and all patients reported efficient block analgesia after bolus injection. Dermatomal numbness decreased gradually and was minimal by 48 h following bolus. CONCLUSION: LB can be injected through a peripheral nerve catheter to prolong analgesia after catheter removal.

Incidence, Severity, and Detection of Blood Pressure Perturbations after Abdominal Surgery: A Prospective Blinded Observational Study.

BACKGROUND: Intraoperative and postoperative hypotension are associated with myocardial and kidney injury and 30-day mortality. Intraoperative blood pressure is measured frequently, but blood pressure on surgical wards is usually measured only every 4 to 6 h, leaving long intervals during which hypotension and hypertension may be undetected. This study evaluated the incidence and severity of postoperative hypotension and hypertension in adults recovering from abdominal surgery and the extent to which serious perturbations were missed by routine vital-sign assessments. METHODS: Blood pressure was recorded at 1-min intervals during the initial 48 h in adults recovering from abdominal surgery using a continuous noninvasive monitor. Caregivers were blinded to these measurements and depended on routine vital-sign assessments. Hypotension and hypertension were characterized as time under and above various mean arterial pressure thresholds. RESULTS: Of 502 available patients, 312 patients with high-quality records were analyzed, with a median measurement time of 48 [interquartile range: 41, 48] postoperative hours. Nearly a quarter experienced an episode of mean arterial pressure of less than 70 mm Hg lasting at least 30 min (24%; 95% CI, 20%, 29%), and 18% had an episode of mean arterial pressure of less than 65 mm Hg lasting at least 15 min. Nearly half the patients who had mean arterial pressure of less than 65 mm Hg for at least 15 min (47%; 95% CI, 34%, 61%) were undetected by routine vital-sign assessments. Episodes of mean arterial pressure greater than 110 mm Hg lasting at least 30 min were observed in 42% (95% CI, 37%, 48%) of patients; 7% had mean arterial pressure greater than 130 mm Hg for at least 30 min, 96% of which were missed by routine assessments. Episodes of mean arterial pressure less than 65 mm Hg and mean arterial pressure greater than 110 mm Hg captured by routine vital-sign assessments but not by continuous monitoring occurred in 34 and 8 patients, respectively. CONCLUSIONS: Postoperative hypotension and hypertension were common, prolonged, profound, and largely undetected by routine vital-sign assessments in a cohort of adults recovering from abdominal surgery. Frequent or continuous blood pressure monitoring may detect hemodynamic perturbations more effectively and potentially facilitate treatment.

Real-time Ultrasound-Guided Lumbar Epidural with Transverse Interlaminar View: Evaluation of an In-Plane Technique.

OBJECTIVE: The anatomical landmarks method is currently the most widely used technique for epidural needle insertion and is faced with multiple difficulties in certain patient populations. Real-time ultrasound guidance has been recently used to aid in epidural needle insertion, with promising results. Our aim was to test the feasibility, success rate, and satisfaction associated with a novel real-time ultrasound-guided lumbar epidural needle insertion in the transverse interlaminar view. DESIGN: Prospective descriptive trial on a novel approach. SETTING: Operating room and preoperative holding area at a tertiary care hospital. SUBJECTS: Adult patients presenting for elective open prostatectomy and planned for surgical epidural anesthesia. METHODS: Consented adult patients aged 30-80 years scheduled for open prostatectomy under epidural anesthesia were enrolled. Exclusion criteria included allergy to local anesthetics, infection at the needle insertion site, coagulopathy, and patient refusal. A curvilinear low-frequency (2-5 MHz) ultrasound probe and echogenic 17-G Tuohy needles were used by one of three attending anesthesiologists. Feasibility of epidural insertion was defined as a 90% success rate within 10 minutes. RESULTS: Twenty-two patients were enrolled into the trial, 14 (63.6%) of whom found the process to be satisfactory or very satisfactory. The median time to perform the block was around 4.5 minutes, with an estimated success rate of 95%. No complications related to the epidural block were observed over the 48 hours after the procedure. CONCLUSIONS: We demonstrate the feasibility of a novel real-time ultrasound-guided epidural with transverse interlaminar view.

Methylprednisolone Does Not Reduce Acute Postoperative Pain After Cardiac Surgery: Subanalysis of a Randomized Clinical Trial.

BACKGROUND: Pain after cardiac surgery is largely treated with opioids, but their poor safety profile makes nonopioid medications attractive as part of multimodal pathways. Anti-inflammatory drugs reduce acute postoperative pain, but the role of steroids in reducing acute poststernotomy pain is unclear. We evaluated the association between the intraoperative administration of methylprednisolone and postoperative analgesia, defined as a composite of pain scores and opioid consumption, during the initial 24 hours after cardiac surgery. METHODS: We conducted a post hoc retrospective analysis of a large clinical trial in which adults having cardiac surgery were randomized 1:1 to receive 2 intraoperative doses of 250 mg IV methylprednisolone or placebo. Pain scores and opioid consumption were collected during the initial 24 hours after surgery. Methylprednisolone was considered to be associated with better pain control than placebo if proven noninferior (not worse) on both pain scores (defined a priori with delta of 1 point) and opioid consumption (delta of 20%) and superior to placebo in at least 1 of the 2 outcomes. This test was repeated in the opposite direction (testing whether placebo is better than methylprednisolone on postoperative pain management). RESULTS: Of 251 eligible patients, 127 received methylprednisolone and 124 received placebo. Methylprednisolone was noninferior to placebo on pain with difference in mean (CI) pain scores of -0.25 (-0.71 to 0.21); P < .001. However, methylprednisolone was not noninferior to placebo on opioid consumption (ratio of geometric means [CI]: 1.11 [0.64-1.91]; P = .37). Because methylprednisolone was not noninferior to placebo on both outcomes, we did not proceed to superiority testing based on the a priori stopping rules. Similar results were found when testing the opposite direction. CONCLUSIONS: In this post hoc analysis, we could not identify a beneficial analgesic effect after cardiac surgery associated with methylprednisolone administration. There are currently no data to suggest that methylprednisolone has significant analgesic benefit in adults having cardiac surgery.

Simulation Versus Problem Based Learning for Cerebrospinal Drainage Catheter Insertion and Management: A Randomized Trial in a Large Academic Anesthesiology Residency Program.

OBJECTIVE: Cerebrospinal fluid drainage catheter-related complications can be reduced by following strict guidelines during their introduction, maintenance, and removal. The authors therefore aimed to determine whether simulation-based learning would improve senior anesthesiology residents' patient care performance during the insertion and management of these catheters compared to interactive problem-based learning (PBL) using the Anaesthetists' Non-Technical Skills global rating scale (ANTS). DESIGN: Prospective randomized trial. SETTING: Vascular or hybrid operating rooms in a large academic tertiary care center. PARTICIPANTS: Senior anesthesia (categorical anesthesia-3) residents rotating through the vascular rotation at the Cleveland Clinic main campus in the period between December 2014 and June 2017. INTERVENTION: Simulation-based learning versus PBL. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the composite score (ANTS global rating scale) achieved by participating residents as evaluated by their supervising anesthesiologists. Out of 28 residents who completed the study, N = 13 were randomized to simulation-based learning and N = 15 residents to the PBL approach. The median (first quartile, third quartile) composite score was 16 (14, 16) and 16 (13, 16) for the simulation-based learning and PBL groups, respectively. There was no significant difference in staff evaluation of the 2 study groups (p = 0.48) with an estimated odds (95% confidence interval) of getting a better staff evaluation score of 1.9 (0.3-10.6) times higher comparing simulation versus traditional training groups. CONCLUSION: Compared to interactive PBL, simulation-based learning does not result in a statistically significant improvement in anesthesia resident performance during insertion and management of cerebrospinal fluid drainage catheters.

Postoperative Hypotension and Surgical Site Infections After Colorectal Surgery: A Retrospective Cohort Study.

BACKGROUND: Hypotension compromises local tissue perfusion, thereby reducing tissue oxygenation. Hypotension might thus be expected to promote infection. Hypotension on surgical wards, while usually less severe than intraoperative hypotension, is common and often prolonged. In this retrospective cohort study, we tested the hypotheses that there is an association between surgical site infections and low postoperative time-weighted average mean arterial pressure and/or postoperative minimum mean arterial pressure. METHODS: We considered patients who had colorectal surgery lasting ≥1 hour at the Cleveland Clinic between 2009 and 2013. We defined blood pressure exposures as time-weighted average (primary) and minimum mean arterial pressure (secondary) within 72 hours after surgery. We assessed associations between continuous blood pressure exposures with a composite of deep and superficial surgical site infection using separate severity-weighted average relative effect generalized estimating equations models, each using an unstructured correlation structure and adjusting for potentially confounding variables. RESULTS: A total of 5896 patients were eligible for analysis. Time-weighted mean arterial pressure and surgical site infection were not significantly associated, with an estimated odds ratio (95% CI) of 1.03 (0.99-1.08) for a 5-mm Hg decrease (P = .16). However, there was a significant inverse association between minimum postoperative mean arterial pressure and infection, with an estimated odds ratio of 1.08 (1.03-1.12) per 5-mm Hg decrease (P = .001). CONCLUSIONS: Postoperative time-weighted mean arterial pressure was not associated with surgical site infection, but lowest postoperative mean arterial pressure was. Whether the relationship is causal remains to be determined.

Preoperative ultrasound assessment of gastric content in patients with diabetes: A meta-analysis based on a systematic review of the current literature.

STUDY OBJECTIVE: To conduct a systematic literature review of the current evidence on the effect of diabetes mellitus on gastric volume observed during a preoperative ultrasound examination. Using the results of this systematic literature review, a meta-analysis was performed to investigate whether there was an association between diabetes mellitus and an increased risk of presenting with a high-risk stomach (gastric volume associated with an increased risk of pulmonary aspiration). DESIGN: Review article and meta-analysis. SETTING: Review of published literature. PATIENTS: A total of 3366 patients underwent surgery. INTERVENTION: Gastric ultrasound examination. MEASUREMENTS: Data for the meta-analysis and literature review were collected from the PubMed/Medline, Embase, Web of Science, and Google Scholar databases of the National Library of Medicine from the date of inception to January 2023. All included studies measured the gastric antral cross-sectional area and/or gastric residual volume in patients with diabetes and those without diabetes. The data utilized in the meta-analysis included all studies that evaluated the incidence of high-risk stomachs based on ultrasonographic measurements of the gastric antral cross-sectional area or gastric residual volume. MAIN RESULTS: Most collated studies revealed that diabetes mellitus was associated with increased antral cross-sectional area and gastric residual volume. A meta-analysis of published reports indicated that patients with diabetes have an increased rate of high-risk stomachs. CONCLUSIONS: Diabetes mellitus is associated with an increased rate of high-risk stomachs. The authors recommend large prospective trials to ascertain the safety of the current fasting guidelines for patients with diabetes undergoing surgery.

Intra-Operative Hypotension is an Important Modifiable Risk Factor for Major Complications in Spinal Fusion Surgery.

STUDY DESIGN: Retrospective observational cohort. OBJECTIVES: This study explores the impact of Intraoperative hypotension (IOH)on post-op complications for major thoracolumbar spine fusion procedures. SUMMARY OF BACKGROUND DATA: IOH with mean arterial pressure (MAP) < 65 mmHg is associated with post-op acute kidney injury (AKI) in general surgery. In spinal deformity surgery, IOH is a contributing factor to MEP changes and spinal cord dysfunction with deformity correction. METHODS: 539 thoracolumbar fusion cases, > 6 surgical levels and > 3 hours duration were identified. Anesthetic/surgical data included OR time, fluid volume, blood loss, blood product replacement and use of vasopressors. Arterial-line based MAP data was collected at 1 min intervals. Cummulative duration of MAP < 65 mmHg was recorded. IOH within the first hour of surgery vs. the entire case was determined. Post-op course and complications including SSI, GI complications, pulmonary complications, MI, DVT, PE, AKI and encephalopathy were noted. Cumulative complications were grouped as none, 1-2 complications, or >3 complications. RESULTS: There was a significant association between occurrence of complications and duration of IOH within the first hour of surgery (8.2 vs. 5.6 min, P<0.001) and across the entire procedure (28.1 vs. 19.3 min, P=0.008). This association persisted for individual major complications including SSI, acute respiratory failure, PE, ileus requiring NGT and post-operative cognitive dysfunction. Comparison of patients with 0 vs. 1-2 vs. 3 or more complications demonstrated that patients with 3 or more complications had a longer duration of IOH in the first hour of the surgery and that patients who had no complications received less vasopressor than patients who had 1-2 or 3 or more complications. CONCLUSION: This study identifies duration of IOH during the first hour of surgery as a previously unrecognized modifiable risk associated with major complications for multi-level lumbar fusion surgery.

Intraoperative hypotension in ambulatory surgery centers.

STUDY OBJECTIVES: To measure the incidence of intraoperative hypotension (IOH) during surgery in ambulatory surgery centers (ASCs) and describe associated characteristics of patients and procedures. DESIGN: Retrospective analysis. SETTING: 20 ASCs. PATIENTS: 16,750 patients having non-emergent, non-cardiac surgery; ASA physical status 2 through 4. INTERVENTIONS: None. MEASUREMENTS: We assessed incidence of IOH using the definition from the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS)-mean arterial pressure (MAP) < 65 mmHg for at least 15 cumulative minutes-and three secondary definitions: minutes of MAP <65 mmHg, area under MAP of 65 mmHg, and time-weighted average MAP <65 mmHg. MAIN RESULTS: 30.9% of ASC cases had a MAP <65 mmHg for at least 15 min. The incidence of IOH varied significantly, and was higher among younger adults (age 18-39; 36.2%), females (35.2%), and patients with ASA physical status 2 (32.8%). IOH increased with increasing surgery length, even when time-weighted, and was higher among low complexity (30.6%) than moderate complexity (28.8%) procedures, and highest among high complexity procedures (44.1%). CONCLUSIONS: There was substantial occurrence of IOH in ASCs, similar to that described in academic hospital settings in previous literature. We hypothesize that this may reflect clinician preference not to intervene in perceived healthy patients or assumptions about ability to tolerate lower blood pressures on behalf of these patients. Future research will determine whether IOH in ACSs is associated with adverse outcomes to the same extent as described in more complex hospital-based surgeries.

Hypoventilation in the PACU is associated with hypoventilation in the surgical ward: Post-hoc analysis of a randomized clinical trial.

OBJECTIVE: To evaluate the association between early postoperative hypoventilation in the last hour of the post-anesthesia care unit (PACU) stay and hypoventilation during the rest of the first 48 postoperative hours in the surgical ward. DESIGN: Sub-analysis of a clinical trial. SETTING: PACU and surgical wards of a single medical center. PATIENTS: Adults having abdominal surgery under general anesthesia. INTERVENTIONS: Monitoring with a respiratory volume monitor from admission to PACU until the earlier of 48 h after surgery or discharge. MEASUREMENTS: The exposure was having at least one low minute-ventilation (MV) event during the last hour of PACU stay, defined as MV lower than 40% the predicted value lasting at least 1 min. The primary outcome was low MV events lasting at least 2 min during the rest of the first 48 postoperative hours, while in the surgical ward. The secondary outcome was the rate of low MV events per monitored hour. MAIN RESULTS: Data of 292 patients were analyzed, of which 20 (6.8%) patients had a low MV event in PACU. Low MV events in the surgical ward were found in 81 (28%) patients. All patients who had low MV events in PACU had events again in the ward, while 61/272 (22%) had an event in the ward but not in PACU. The incidence rate of low MV events per hour was 24 (95% CI: 13, 46) among patients having an event in the PACU, and 2 (1, 4) among those who did not. CONCLUSIONS: In adults recovering from abdominal surgery, events of hypoventilation during the first postoperative hour are associated with similar events during the rest of the first 48 postoperative hours, with positive predictive value approaching 100%. Sixty-one patients had ward hypoventilation that was not preceded by hypoventilation in PACU.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis.

BACKGROUND: Intraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. OBJECTIVES: To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians. METHODS: Design Cross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021. Setting Forty-five facilities affiliated with two large anesthesia providers in the USA. Participants Patients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases. Main outcomes IOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg. RESULTS: Among 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses. CONCLUSION: Intraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered "low risk." Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.

Coring Revisited: A Case Report and Literature Review.

Coring is the retention of material from a medication vial into the needle and syringe, which can ultimately be transfused into a patient, causing adverse outcomes. The purpose of this article is to increase awareness of this underreported finding and to propose solutions to improve the quality of care and decrease fatalities. A 65-year-old male with a significant cardiovascular history was admitted and required an emergent bedside esophagogastroduodenoscopy, for which propofol was being aspirated for IV induction. This resulted in the coring of the vial topper and subsequently a rubber piece in the syringe. The prevention of coring has largely focused on anticipating the shortcomings of currently available medication vials and aspiration techniques. However, these strategies have limitations. Further work can highlight risk-mitigating approaches such as different aspiration techniques, needle or vial types, and prefilled syringes. More importantly, these interventions may reduce perioperative morbidity and mortality.

Intravenous Lipid Emulsion for the Treatment of Perioperative Cocaine Intoxication.

Symptomatic cocaine intoxication in the preoperative period is a potentially life-threatening condition, especially before emergent surgery. The anesthesiologist is faced with a dilemma where the patient is deemed unsafe for induction of general anesthesia but also in need of immediate surgical intervention. Cocaine is a local anesthetic and, as such, has been proposed to respond to lipid emulsion treatment as other local anesthetics would. We present a case supporting this statement and review the relevant published literature on the topic.

The cost-effectiveness of epidural, patient-controlled intravenous opioid analgesia, or transversus abdominis plane infiltration with liposomal bupivacaine for postoperative pain management.

STUDY OBJECTIVE: Intravenous patient-controlled opioid analgesia (IVPCA), epidural analgesia and transversus abdominis plane (TAP) infiltrations are frequently used postoperative pain management modalities. The aim of this study was to conduct a cost-effectiveness analysis comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively in patients undergoing major lower abdominal surgery. DESIGN: Retrospective cost effectiveness analysis. SETTING: Operating room. PATIENTS: We obtained data on major lower-abdominal surgeries performed under general anesthesia on adult patients between January 2012 and July 2014. INTERVENTIONS: A cost-effectiveness analysis was comparing the use of epidural, IVPCA, and TAP infiltrations with liposomal bupivacaine for analgesia in the first 72 h postoperatively. MEASUREMENTS: A decision analytic model was used to estimate the health outcomes for patients undergoing major lower abdominal surgery. The primary outcome was time-weighted pain from 0 to 72 h after surgery, as measured by numerical rating scale pain scores. The analysis was conducted from the perspective of the hospital as the party responsible for most costs related to surgery. MAIN RESULTS: From the base case analysis, IVPCA was the optimal strategy regarding cost and effect. TAP with LB, however, was only narrowly dominated, while epidural was clearly dominated. From the sensitivity analysis at willingness-to-pay (WTP) of $150, IV PCA and TAP infiltration were each the optimal strategy for approximately 50% of the iterations. At WTP of $10,000, epidural was only the optimal strategy in 10% of the iterations. CONCLUSIONS: This is the first study in the literature to compare the cost-effectiveness of epidural, IVPCA, and TAP infiltrations with LB. Within reasonable WTP values, there is little differentiation in cost-effectiveness between IVPCA and TAP infiltration with LB. Epidural does not become a cost-effective strategy even at much higher WTP values.

Ultrasound Pulsed-Wave Doppler Detects an Intrathecal Location of an Epidural Catheter Tip: A Case Report.

Currently, no gold standard method exists for localization of an epidural catheter after placement. The technique described in this report uses pulsed-wave Doppler (PWD) ultrasound to identify intrathecal location of an epidural catheter. A thoracic epidural catheter was inserted after multiple trials with inconclusive aspiration and test dose. Ultrasound PWD confirmed no flow in the epidural space and positive flow in the intrathecal space. A fluid aspirate was positive for glucose, reconfirming intrathecal placement. PWD is a potential tool that can be used to locate the tip of an epidural catheter.

Postoperative Stridor and Acute Respiratory Failure After Parkinson Disease Deep Brain Stimulator Placement: Case Report and Review of Literature.

BACKGROUND: Parkinson disease (PD), a neurodegenerative disorder characterized by loss of dopaminergic neurons in the substantia nigra of the midbrain, is commonly thought of as a motion disorder, but it can have significant effect on the respiratory system. Respiratory failure is the most common cause of death in these patients, but it can also affect laryngeal function causing dysphonia, dysphagia, and dysarthric speech. Acute upper airway obstruction is a rare finding in PD, especially in the perioperative settings. In this article we report a PD patient who developed upper respiratory obstruction postoperatively. We also review the literature and highlight the importance of preoperative evaluation to identify patients who may be at risk of this complication. CASE DESCRIPTION: We describe a PD patient presenting for brain stimulation electrode implantation under general anesthesia, who postoperatively developed stridor and near complete upper airway obstruction despite maintenance of oral anti-Parkinson medication regimen intraoperatively. The patient was reintubated in post-anesthesia-care unit, and tracheostomy was performed after 1 week due to persistent vocal cord dysfunction. CONCLUSIONS: Baseline vocal cord impairment in PD patients can be acutely aggravated perioperatively. Symptoms such as dysphagia and dysarthria, which can indicate susceptibility to postoperative upper airway obstruction, may not be well recognized by the patient and family. Surgical candidates should be carefully interviewed preoperatively, and watchful monitoring of respiratory function intraoperatively and postoperatively is of paramount importance. Neurosurgical and neuroanesthesia team should be aware of, and prepared to manage, this potentially life-threatening airway obstruction in PD patients.