Anaesthetic care of patients undergoing primary hip and knee arthroplasty: consensus recommendations from the International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) based on a systematic review and meta-analysis.

BACKGROUND: Evidence-based international expert consensus regarding anaesthetic practice in hip/knee arthroplasty surgery is needed for improved healthcare outcomes. METHODS: The International Consensus on Anaesthesia-Related Outcomes after Surgery group (ICAROS) systematic review, including randomised controlled and observational studies comparing neuraxial to general anaesthesia regarding major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, genitourinary, thromboembolic, neurological, infectious, and bleeding complications. Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, from 1946 to May 17, 2018 were queried. Meta-analysis and Grading of Recommendations Assessment, Development and Evaluation approach was utilised to assess evidence quality and to develop recommendations. RESULTS: The analysis of 94 studies revealed that neuraxial anaesthesia was associated with lower odds or no difference in virtually all reported complications, except for urinary retention. Excerpt of complications for neuraxial vs general anaesthesia in hip/knee arthroplasty, respectively: mortality odds ratio (OR): 0.67, 95% confidence interval (CI): 0.57-0.80/OR: 0.83, 95% CI: 0.60-1.15; pulmonary OR: 0.65, 95% CI: 0.52-0.80/OR: 0.69, 95% CI: 0.58-0.81; acute renal failure OR: 0.69, 95% CI: 0.59-0.81/OR: 0.73, 95% CI: 0.65-0.82; deep venous thrombosis OR: 0.52, 95% CI: 0.42-0.65/OR: 0.77, 95% CI: 0.64-0.93; infections OR: 0.73, 95% CI: 0.67-0.79/OR: 0.80, 95% CI: 0.76-0.85; and blood transfusion OR: 0.85, 95% CI: 0.82-0.89/OR: 0.84, 95% CI: 0.82-0.87. CONCLUSIONS: Recommendation: primary neuraxial anaesthesia is preferred for knee arthroplasty, given several positive postoperative outcome benefits; evidence level: low, weak recommendation. RECOMMENDATION: neuraxial anaesthesia is recommended for hip arthroplasty given associated outcome benefits; evidence level: moderate-low, strong recommendation. Based on current evidence, the consensus group recommends neuraxial over general anaesthesia for hip/knee arthroplasty. TRIAL REGISTRY NUMBER: PROSPERO CRD42018099935.

Do the choices of airway affect the post-anesthetic occurrence of nausea after knee arthroplasty? A comparison between endotracheal tubes and laryngeal mask airways.

OBJECTIVES: The primary goal of this study was to assess the impact of airway devices on the incidence of nausea after knee arthroplasty and their interaction with the use of nitrous oxide. METHODS: Charts were reviewed for 499 patients after knee arthroplasty under general anesthesia. Demographic data, type of airway device, nitrous oxide, sevoflurane, desflurane, isoflurane, fentanyl, metoclopramide, ondansetron, dexamethasone, rocuronium and neostigmine were analyzed. Fisher's exact test was used to compare the categorical factors and t-test was used for continuous variables. Sinclair scores were used for post-operative nausea and vomiting (PONV) risk stratification. Multivariate logistic regression model was constructed to identify the factors contributing to the frequency of PONV. RESULTS: PONV was documented in 10.3% of patients. Nitrous oxide was associated with a higher frequency of PONV than those received air mixture (12.5% vs. 8.7%, P < 0.01). Prior to risk stratification, the frequency of PONV was 17% in the endotracheal tube (ETT) vs. 6.7% in the laryngeal mask airway (LMA) group (P < 0.01). Sinclair score was 0.51 +/- 0.17 for the ETT group and 0.74 +/- 0.12 for the LMA group (P < 0.001). After risk stratification and matching, the incidence of PONV was 15.8% with the use of ETT compared with 7.9% for LMA (P < 0.05). CONCLUSION: The frequency of PONV was almost twice with ETT as with LMA. Longer duration of anesthesia, neuromuscular blockade and non-standardized antiemetic regimen may have contributed to the increase PONV in ETT group. Prospective randomized studies are necessary to further explore whether and to which extend airway devices influence the incidence of PONV.

Retrospective study of the effect of opioid prescribing guidelines on prescribing practices in pediatric orthopedic sports medicine patients having knee surgery: A single institution's experience.

OBJECTIVE: Guidelines for opioid prescription post-operatively exist; however, the majority of these are for adults. Nevertheless, opioid risks are present for pediatric patients also. This study investigates the effect of a single institution's guidelines on post-operative opioid prescribing for pediatric orthopedic patients undergoing knee surgery. We hypothesized that a standardized set of prescribing guidelines would result in a decrease in opioids prescribed at discharge home after these surgeries. DESIGN: Retrospective observational. SETTING: Urban, tertiary care, academic orthopedic hospital. PATIENTS: Pediatric, sports knee surgery, 23-month period. INTERVENTIONS: Guidelines were implemented institutionally for post-operative opioid prescribing practices. We reviewed all post-operative opioid prescriptions for pediatric patients undergoing sports knee surgery with two pediatric sports surgeons for the 11 months prior to the guidelines and 12 months afterwards, totaling 316 surgeries. MAIN OUTCOME MEASURE: Oral morphine equivalents (OMEs) prescribed on discharge from the hospital before and after implementation of guidelines. RESULTS: There was a significant reduction in OMEs from 229 OMEs to 175 OMEs before and after opioid prescribing guidelines (p < 0.001). This is a decrease in approximately seven 5 mg oxycodone tablets per patient. CONCLUSIONS: This study demonstrates that at our institution, with a pediatric patient population having sports knee surgery, prescribing guidelines reduced the number of opioids prescribed at discharge.

More than half of opioids prescribed to pediatric patients after ambulatory knee surgery are unused.

OBJECTIVE: To determine the number of opioid pills remaining after pediatric ambulatory knee surgery to provide insight into how many pills are actually used. DESIGN: Prospective observational cohort study. Participants who were expected to be prescribed 20 (Group 1) versus 40 (Group 2) opioid pills according to the institutional policy (based on the type of surgery) were studied. Patient's reported pain, medication use, and number of opioid pills remaining at post-operative days (PODs) 7 and 14. Participants were not randomly assigned to groups and no intervention was applied. SETTING: An urban tertiary care musculoskeletal institution. PARTICIPANTS: Sixty adolescents between the ages of 12 and 19 undergoing ambulatory knee surgery. INTERVENTIONS: Observational study, no experimental study intervention. MAIN OUTCOME MEASURE: The total number of opioid pills remaining. RESULTS: By POD7, more than 70 percent of patients had stopped taking their prescribed opioid medication mainly because their knee pain was tolerable either without the opioid or by using other medications. By POD14, the mean number of pills taken was 6.3 ± 5.3 for Group 1 and 18.4 ± 13.9 for Group 2. The mean number of unused opioids was 13.5 ± 7.2 for Group 1 and 17.9 ± 13.7 for Group 2. CONCLUSIONS: Even with prescribing practice guidelines in place, opioids may be overprescribed and could be given in a smaller quantity without affecting the quality of acute postoperative pain control in adolescents undergoing ambulatory knee surgery. However, one needs to consider that some patients may need a larger than average amount in order to be appropriately treated for their level of pain and thus prescription amounts-preferably after reevaluation-should be individualized.

Peripheral nerve block anesthesia/analgesia for patients undergoing primary hip and knee arthroplasty: recommendations from the International Consensus on Anesthesia-Related Outcomes after Surgery (ICAROS) group based on a systematic review and meta-analysis of current literature.

BACKGROUND: Evidence-based international expert consensus regarding the impact of peripheral nerve block (PNB) use in total hip/knee arthroplasty surgery. METHODS: A systematic review and meta-analysis: randomized controlled and observational studies investigating the impact of PNB utilization on major complications, including mortality, cardiac, pulmonary, gastrointestinal, renal, thromboembolic, neurologic, infectious, and bleeding complications.Medline, PubMed, Embase, and Cochrane Library including Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, were queried from 1946 to August 4, 2020.The Grading of Recommendations Assessment, Development, and Evaluation approach was used to assess evidence quality and for the development of recommendations. RESULTS: Analysis of 122 studies revealed that PNB use (compared with no use) was associated with lower ORs for (OR with 95% CIs) for numerous complications (total hip and knee arthroplasties (THA/TKA), respectively): cognitive dysfunction (OR 0.30, 95% CI 0.17 to 0.53/OR 0.52, 95% CI 0.34 to 0.80), respiratory failure (OR 0.36, 95% CI 0.17 to 0.74/OR 0.37, 95% CI 0.18 to 0.75), cardiac complications (OR 0.84, 95% CI 0.76 to 0.93/OR 0.83, 95% CI 0.79 to 0.86), surgical site infections (OR 0.55 95% CI 0.47 to 0.64/OR 0.86 95% CI 0.80 to 0.91), thromboembolism (OR 0.74, 95% CI 0.58 to 0.96/OR 0.90, 95% CI 0.84 to 0.96) and blood transfusion (OR 0.84, 95% CI 0.83 to 0.86/OR 0.91, 95% CI 0.90 to 0.92). CONCLUSIONS: Based on the current body of evidence, the consensus group recommends PNB use in THA/TKA for improved outcomes. RECOMMENDATION: PNB use is recommended for patients undergoing THA and TKA except when contraindications preclude their use. Furthermore, the alignment of provider skills and practice location resources needs to be ensured. Evidence level: moderate; recommendation: strong.

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.