Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults.

BACKGROUND: The effects of spinal anesthesia as compared with general anesthesia on the ability to walk in older adults undergoing surgery for hip fracture have not been well studied. METHODS: We conducted a pragmatic, randomized superiority trial to evaluate spinal anesthesia as compared with general anesthesia in previously ambulatory patients 50 years of age or older who were undergoing surgery for hip fracture at 46 U.S. and Canadian hospitals. Patients were randomly assigned in a 1:1 ratio to receive spinal or general anesthesia. The primary outcome was a composite of death or an inability to walk approximately 10 ft (3 m) independently or with a walker or cane at 60 days after randomization. Secondary outcomes included death within 60 days, delirium, time to discharge, and ambulation at 60 days. RESULTS: A total of 1600 patients were enrolled; 795 were assigned to receive spinal anesthesia and 805 to receive general anesthesia. The mean age was 78 years, and 67.0% of the patients were women. A total of 666 patients (83.8%) assigned to spinal anesthesia and 769 patients (95.5%) assigned to general anesthesia received their assigned anesthesia. Among patients in the modified intention-to-treat population for whom data were available, the composite primary outcome occurred in 132 of 712 patients (18.5%) in the spinal anesthesia group and 132 of 733 (18.0%) in the general anesthesia group (relative risk, 1.03; 95% confidence interval [CI], 0.84 to 1.27; P = 0.83). An inability to walk independently at 60 days was reported in 104 of 684 patients (15.2%) and 101 of 702 patients (14.4%), respectively (relative risk, 1.06; 95% CI, 0.82 to 1.36), and death within 60 days occurred in 30 of 768 (3.9%) and 32 of 784 (4.1%), respectively (relative risk, 0.97; 95% CI, 0.59 to 1.57). Delirium occurred in 130 of 633 patients (20.5%) in the spinal anesthesia group and in 124 of 629 (19.7%) in the general anesthesia group (relative risk, 1.04; 95% CI, 0.84 to 1.30). CONCLUSIONS: Spinal anesthesia for hip-fracture surgery in older adults was not superior to general anesthesia with respect to survival and recovery of ambulation at 60 days. The incidence of postoperative delirium was similar with the two types of anesthesia. (Funded by the Patient-Centered Outcomes Research Institute; REGAIN ClinicalTrials.gov number, NCT02507505.).

Long-term Outcomes with Spinal versus General Anesthesia for Hip Fracture Surgery: A Randomized Trial.

BACKGROUND: The effects of spinal versus general anesthesia on long-term outcomes have not been well studied. This study tested the hypothesis that spinal anesthesia is associated with better long-term survival and functional recovery than general anesthesia. METHODS: A prespecified analysis was conducted of long-term outcomes of a completed randomized superiority trial that compared spinal anesthesia versus general anesthesia for hip fracture repair. Participants included previously ambulatory patients 50 yr of age or older at 46 U.S. and Canadian hospitals. Patients were randomized 1:1 to spinal or general anesthesia, stratified by sex, fracture type, and study site. Outcome assessors and investigators involved in the data analysis were masked to the treatment arm. Outcomes included survival at up to 365 days after randomization (primary); recovery of ambulation among 365-day survivors; and composite endpoints for death or new inability to ambulate and death or new nursing home residence at 365 days. Patients were included in the analysis as randomized. RESULTS: A total of 1,600 patients were enrolled between February 12, 2016, and February 18, 2021; 795 were assigned to spinal anesthesia, and 805 were assigned to general anesthesia. Among 1,599 patients who underwent surgery, vital status information at or beyond the final study interview (conducted at approximately 365 days after randomization) was available for 1,427 (89.2%). Survival did not differ by treatment arm; at 365 days after randomization, there were 98 deaths in patients assigned to spinal anesthesia versus 92 deaths in patients assigned to general anesthesia (hazard ratio, 1.08; 95% CI, 0.81 to 1.44, P = 0.59). Recovery of ambulation among patients who survived a year did not differ by type of anesthesia (adjusted odds ratio for spinal vs. general, 0.87; 95% CI, 0.67 to 1.14; P = 0.31). Other outcomes did not differ by treatment arm. CONCLUSIONS: Long-term outcomes were similar with spinal versus general anesthesia.

Does the Case Volume Experience of the Anesthesiologist Influence the Intraoperative Efficiency at All?

This editorial discusses the recent study conducted by Macias et al., revealing that anesthesiologists' case volume history has only a marginal impact on improving operating room efficiency, resulting in minimal clinical significance. The idea that a specific anesthesia team or type of anesthesia could enhance productivity has been previously investigated, yielding similar conclusions. Although the study primarily focuses on the time from patient arrival to the completion of anesthesia induction, excluding the latter part of anesthesia-controlled time, Macias et al. have made a valuable contribution by challenging the prevalent notion that less experienced anesthesiologists adversely affect operating room efficiency.

Pain, Analgesic Use, and Patient Satisfaction With Spinal Versus General Anesthesia for Hip Fracture Surgery : A Randomized Clinical Trial.

BACKGROUND: The REGAIN (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) trial found similar ambulation and survival at 60 days with spinal versus general anesthesia for hip fracture surgery. Trial outcomes evaluating pain, prescription analgesic use, and patient satisfaction have not yet been reported. OBJECTIVE: To compare pain, analgesic use, and satisfaction after hip fracture surgery with spinal versus general anesthesia. DESIGN: Preplanned secondary analysis of a pragmatic randomized trial. (ClinicalTrials.gov: NCT02507505). SETTING: 46 U.S. and Canadian hospitals. PARTICIPANTS: Patients aged 50 years or older undergoing hip fracture surgery. INTERVENTION: Spinal or general anesthesia. MEASUREMENTS: Pain on postoperative days 1 through 3; 60-, 180-, and 365-day pain and prescription analgesic use; and satisfaction with care. RESULTS: A total of 1600 patients were enrolled. The average age was 78 years, and 77% were women. A total of 73.5% (1050 of 1428) of patients reported severe pain during the first 24 hours after surgery. Worst pain over the first 24 hours after surgery was greater with spinal anesthesia (rated from 0 [no pain] to 10 [worst pain imaginable]; mean difference, 0.40 [95% CI, 0.12 to 0.68]). Pain did not differ across groups at other time points. Prescription analgesic use at 60 days occurred in 25% (141 of 563) and 18.8% (108 of 574) of patients assigned to spinal and general anesthesia, respectively (relative risk, 1.33 [CI, 1.06 to 1.65]). Satisfaction was similar across groups. LIMITATION: Missing outcome data and multiple outcomes assessed. CONCLUSION: Severe pain is common after hip fracture. Spinal anesthesia was associated with more pain in the first 24 hours after surgery and more prescription analgesic use at 60 days compared with general anesthesia. PRIMARY FUNDING SOURCE: Patient-Centered Outcomes Research Institute.

Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial.

INTRODUCTION: The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown. METHODS: Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery. RESULTS: Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment. DISCUSSION: Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.

A Role for Gastric Point of Care Ultrasound in Postoperative Delayed Gastrointestinal Functioning.

INTRODUCTION: Delayed bowel function (DBF) and postoperative ileus (POI) are common gastrointestinal complications after surgery. There is no reliable imaging study to help diagnose these complications, forcing clinicians to rely solely on patient history and physical exam. Gastric point of care ultrasound (POCUS) is a simple bedside imaging technique to evaluate gastric contents but has not been evaluated in postoperative patients. METHODS: Twenty colorectal patients were enrolled in this pilot study. Patients were categorized as either full or empty stomach based upon their postoperative day one gastric POCUS exams and previously published definitions. The primary outcome was GI-3 recovery, a dual end point defined as tolerance of solid food and either flatus or bowel movement. Secondary outcomes were length of stay, emesis, time to first flatus, time to first bowel movement, nasogastric tube placement, aspiration events, and mortality. RESULTS: Nine of 20 patients had a full stomach postoperatively. Patients with full stomachs were younger and received greater perioperative opioid doses (74.0 ± 28.2 v 42.6 ± 32.9 morphine equivalents, P = 0.0363) compared to empty stomach patients. GI-3 recovery occurred significantly later for patients with postoperative day 1 full stomachs (2.1 ± 0.4 versus 1 ± 0 days, P = 0.00091). CONCLUSIONS: Based upon this pilot study, gastric POCUS may hold promise as a noninvasive and simple bedside modality to potentially help identify colorectal patients at risk for postoperative DBF and POI and should be evaluated in a larger study.

Regional versus general anesthesia for ambulatory total hip and knee arthroplasty.

PURPOSE OF REVIEW: With the removal of both total knee and total hip arthroplasty from the Centers for Medicare and Medicaid Services' inpatient-only list, efforts to improve efficiency of the perioperative management of total joint patients have increased recently. The publication of several recent studies examining the impact of anesthesia type on outcomes has prompted the need to review the overall state of evidence for spinal versus general anesthesia for outpatient total joint arthroplasty. RECENT FINDINGS: Overall complication rates are low in this carefully selected patient population. The majority of patients who are preselected for outpatient total joint arthroplasty appear to successfully achieve this outcome. Some retrospective studies have suggested a benefit for spinal anesthesia in terms of same-day discharge success but direct comparisons in prospective studies are lacking. SUMMARY: The type of anesthesia used for total joint arthroplasty may have an important effect on outcomes. Until randomized control trials are performed we must rely on existing evidence, which suggests that both spinal and general anesthesia can lead to successful outcomes after ambulatory total joint arthroplasty.

Beyond the Raskin Protocol: Ketamine, Lidocaine, and Other Therapies for Refractory Chronic Migraine.

PURPOSE OF REVIEW: The purpose of this review is to discuss the available evidence and therapeutic considerations for intravenous drug therapy for refractory chronic migraine. RECENT FINDINGS: In carefully monitored settings, the inpatient administration of intravenous lidocaine and ketamine can be successful in treating refractory chronic migraine. Many patients with refractory chronic migraine have experienced treatment failure with the Raskin protocol. The use of aggressive inpatient infusion therapy consisting of intravenous lidocaine or ketamine, along with other adjunctive medications, has become increasingly common for these patients when all other treatments have failed. There is a clear need for prospective studies in this population comprised of patients who have largely been excluded from other studies.

Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity.

PURPOSE OF REVIEW: While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented. RECENT FINDINGS: Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.

Risk of Gastrointestinal Bleeding With Extended Use of Nonsteroidal Anti-Inflammatory Drug Analgesia After Joint Arthroplasty.

BACKGROUND: Chronic nonsteroidal anti-inflammatory drug (NSAID) use is associated with gastrointestinal bleeding via inhibition of endogenous mucosal protection and platelet aggregation. This study aimed to determine whether extended NSAIDs after joint arthroplasty is associated with increased risk of gastrointestinal bleeding. METHODS: This was a retrospective study examining 28,794 adults who underwent joint arthroplasty by one of 50 surgeons from 2016 to 2018. Episodes of gastrointestinal bleeding within 90 days postoperatively were identified prospectively. Postoperative medications were reported directly by patients with electronic questionnaires. The primary analysis was performed using binary logistic regression. RESULTS: A total of 74 (0.26%) episodes of gastrointestinal bleeding occurred within 90 days (median 8 days) postoperatively. Of 5086 patients with complete data included in the primary analysis, 59.6% had used NSAIDs with median duration of 2 weeks (interquartile range, 0-6 weeks). Patients with gastrointestinal bleeding were significantly older (71.3 vs 67.0 years), required longer hospitalizations (2.1 vs 1.5 days), and more commonly had a history of peptic ulcers (10.8% vs 0.9%). However, there was no positive association between NSAID use and gastrointestinal bleeding. In fact, the odds of gastrointestinal bleeding were lower in patients taking NSAIDs. Gastrointestinal bleeding was associated with anticoagulants, antiplatelet agents, and, to a lesser extent, aspirin. CONCLUSION: NSAIDs were not associated with gastrointestinal bleeding and may be prescribed safely for a majority of patients after joint arthroplasty. The greatest odds of gastrointestinal bleeding occurred in patients with peptic ulcer disease and those who received antiplatelet and anticoagulation agents. Increasing age and bilateral surgery were also associated with gastrointestinal bleeding. LEVEL OF EVIDENCE: Level III.

A Randomized Trial of Manual Phone Calls Versus Automated Text Messages for Peripheral Nerve Block Follow-Ups.

Mobile phone applications (apps) have been used for patient follow-up in the postoperative period, specifically to assess for complications and patient satisfaction. Few studies have evaluated their use in regional anesthesia. The objective of this study was to compare follow-up response rates using manual phone calls versus an automated patient outreach (APO) app for peripheral nerve block patients. We hypothesized that the response rate would be higher in the APO group. A mobile app, "JeffAnesthesia," was developed, which sends notifications to patients to answer survey questions in the app. We randomly assigned patients who received peripheral nerve blocks for postoperative pain to either a manual phone call or an APO app group, with follow-up in each category occurring between postoperative days (POD) 14-21 and 90-100. In total, 60 patients were assigned to the phone call group and 60 patients to the APO app group. Between POD 14-21, 9 (15%) patients were reached in the manual phone call arm, and 16 (26.7%) patients were reached in the APO arm (p = 0.117). At POD 90-100, follow-up was successful with 5 (8.2%) in the manual phone call group vs. 3 (5.0%) patients in the APO app group (p = 0.300). Overall response rate was poor, with comparable response rates between groups. The APO method may reduce time spent by anesthesia staff on follow-up calls, but our data do not suggest this method improves response rates significantly. Further studies are needed to better understand the reasons for the poor response rate and strategies for improvement.

An anesthesiologist-led inpatient buprenorphine initiative.

Hospitalized patients with opioid use disorder who present with acute pain are challenging to manage. Without any treatment, their mortality in the first 28 days after discharge is substantially increased. Unlike extended-release naltrexone, which requires a period of withdrawal, or methadone, which can cause prolonged corrected QT (QTc) and carries a higher risk of respiratory depression, buprenorphine provides potent analgesia with low respiratory risk. Hospitalization provides a unique opportunity for clinicians to perform buprenorphine induction, which could potentially reduce mortality without affecting analgesia. Our acute pain management service uses multimodal analgesia to maintain adequate analgesia and minimize withdrawal during buprenorphine induction in the hospital. With the assistance of narcotics addiction rehabilitation program specialists, we help link patients to outpatient buprenorphine providers and maximize the chance of successful recovery. The primary outcome of this study was to determine the percentage of patients who filled an outpatient buprenorphine prescription after undergoing inpatient induction.

Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation.

BACKGROUND: Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty. METHODS: This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5 mg of mepivacaine, 11.25 mg of hyperbaric bupivacaine, or 12.5 mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, same-day discharge, length of stay, and 30-day readmissions. RESULTS: Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness. CONCLUSIONS: Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type.

I Tweet, Therefore I Learn: An Analysis of Twitter Use Across Anesthesiology Conferences.

BACKGROUND: Twitter in anesthesiology conferences promotes rapid science dissemination, global audience participation, and real-time updates of simultaneous sessions. We designed this study to determine if an association exists between conference attendance/registration and 4 defined Twitter metrics. METHODS: Using publicly available data through the Symplur Healthcare Hashtags Project and the Symplur Signals, we collected data on total tweets, impressions, retweets, and replies as 4 primary outcome metrics for all registered anesthesiology conferences occurring from May 1, 2016 to April 30, 2017. The number of Twitter participants, defined as users who contributed a tweet, retweet, or reply 3 days before through 3 days after the conference, was collected. We also collected influencer data as determined by mentions (number of times a user is referenced). Two authors independently verified the categories for influencers assigned by Symplur. Conference demographic data were obtained by e-mail inquiries. Associations between meeting attendees/registrants and Twitter metrics, between Twitter participants and the metrics, and between physician influencers and Twitter participants were tested using Spearman rho. RESULTS: Fourteen conferences with 63,180 tweets were included. With the American Society of Anesthesiologists annual meeting included, the correlations between meeting attendance/registration and total tweets (rs = 0.588; P = .074), impressions (rs = 0.527; P = .117), and retweets (rs = 0.539; P = .108) were not statistically significant; for replies, it was moderately positive (rs = 0.648; P = .043). Without the American Society of Anesthesiologists annual meeting, total tweets (rs = 0.433; P = .244), impressions (rs = 0.350; P = .356), retweets (rs = 0.367; P = .332), and replies (rs = 0.517; P = .154) were not statistically significant. Secondary outcomes include a highly positive correlation between Twitter participation and total tweets (rs = 0.855; P < .001), very highly positive correlations between Twitter participation and impressions (rs = 0.938; P < .001), retweets (rs = 0.925; P < .001), and a moderately positive correlation between Twitter participation and replies (rs = 0.652; P = .044). Doctors were top influencers in 8 of 14 conferences, and the number of physician influencers in the top 10 influencers list at each conference had a moderately positive correlation with Twitter participation (rs = 0.602; P = .023). CONCLUSIONS: We observed that the number of Twitter participants for a conference is positively associated with Twitter activity metrics. No relationship between conference size and Twitter metrics was observed. Physician influencers may be an important driver of participants.

General vs Spinal Anesthesia for Total Joint Arthroplasty: A Single-Institution Observational Review.

BACKGROUND: Total joint arthroplasty (TJA) can be successfully carried out under general (GA) or spinal anesthesia (SA). The existing literature does not adequately illustrate which technique is optimal. The purpose of this study is to prospectively compare the effects of anesthesia technique on TJA outcomes. METHODS: This 2-year, prospective, observational study was conducted at a single institution where patients receiving primary TJA were consecutively enrolled. Patients were contacted postoperatively to assess for any 90-day complications. The primary outcome of the study was the overall complication rate. RESULTS: A total of 2242 patients underwent total hip arthroplasty (n = 656; 29.26%) or total knee arthroplasty (n = 1586; 70.74%) between 2015 and 2017. Of these procedures, 1325 (59.10%) were carried out under SA and 917 (40.90%) were carried out under GA. Patients in the GA cohort had higher mean Charlson Comorbidity Index scores (0.05 SA vs 0.09 GA; P < .05) and higher average body mass index (29.35 SA vs 30.24 GA; P < .05). On multivariate analysis, patients in the SA cohort had a significantly lower overall complication rate relative to their GA counterparts (7.02% vs 10.14%; odds ratio, 0.66; 95% confidence interval, 0.49-0.90; P < .05). In addition, length of stay in the GA cohort was significantly longer (2.43 [SD, 1.62] vs 2.18 [SD, 0.88] days; P < .01) and a larger percentage of GA patients were discharged to a nursing facility (32.28% vs 25.06%; odds ratio, 0.55; 95% confidence interval, 0.44-0.70; P < .05). CONCLUSION: Our study demonstrates that SA for TJA is associated with a decrease in overall complications and healthcare resource utilization.

Ketamine and Cognitive Behavioral Therapy for Rapid Opioid Tapering With Sustained Opioid Abstinence: A Case Report and 1-Year Follow-up.

BACKGROUND: Ketamine, a potent analgesic and N-methyl-D-aspartate-(NMDA)-receptor antagonist, improves analgesic outcomes in patients with complex regional pain syndrome (CRPS). The NMDA receptor has also been implicated in opioid withdrawal. The use of ketamine to assist with a rapid opioid taper in the setting of CRPS has not been previously described. CASE: We present a case in which a 5-day continuous ketamine infusion was utilized in a robust multimodal analgesia regimen in combination with cognitive behavioral therapy (CBT) to successfully taper a patient with complex regional pain syndrome (CRPS) who was taking 330 mg of daily morphine equivalents completely off of opioids, minimize withdrawal symptoms, and produce sustained results. DISCUSSION: CRPS may involve catecholamine hypersensitivity and central sensitization and can be notoriously challenging to treat by itself even outside of the context of an opioid taper. The patient we describe here received one additional 5-day infusion at 6 months and remained opioid-free while experiencing a major improvement in function and lifestyle that he still maintains. This was possible through a combination of aggressive inpatient management with ketamine as the centerpiece, followed by consistent outpatient CBT to maintain results without the need for a return to opioids. This combination has previously not been described in the setting of a rapid opioid taper and this patient's underlying CRPS made it all the more remarkable.

Transdermal Lidocaine for Perioperative Pain: a Systematic Review of the Literature.

PURPOSE OF REVIEW: The purpose of this review is to provide a summary of the perioperative studies that have examined transdermal lidocaine (lidocaine patch) as an analgesic and put the evidence in context of the likely overall benefit of transdermal lidocaine in the perioperative period. RECENT FINDINGS: Several randomized controlled trials have been published in the past 4 years that concluded transdermal lidocaine can reduce acute pain associated with laparoscopic trocar or cannula insertion. Transdermal lidocaine may reduce short-term pain after surgery in selected surgery types and has a low risk of toxicity but its overall clinical utility in the perioperative setting is questionable. Transdermal lidocaine does not consistently reduce opioid consumption after surgery and has not been shown to improve patient function.

Provider Access to Legacy Electronic Anesthesia Records Following Implementation of an Electronic Health Record System.

Many hospitals are in the process of replacing their legacy anesthesia information management system (AIMS) with an Electronic Health Record (EHR) system, within which the AIMS is integrated. Using the legacy AIMS security access log table, we studied the extent to which anesthesia providers were accessing historical anesthesia records (January 2006 - March 2017) following implementation of an EHR (April 2017). Statistical analysis was by segmented regression. At the time of implementation of the EHR, in 44.8% (SE = 0.3%) of cases, there was a prior anesthetic record for the patient that had been documented in the legacy AIMS. Following EHR implementation, the mean number of preoperative clinical views of all prior anesthetic records divided by the total number of cases performed decreased to 2.3% (0.3%) from the baseline of 25.1% (0.8%). The estimated ratio of the 2 means was 0.18 (95% CI 0.11 to 0.31, P < 0.00001). For views of unique records, the decrease was to 2.2% (0.3%) from the baseline of 18.3% (0.5%). The estimated ratio was 0.23 (95% CI 0.15 to 0.35, P < 0.00001). These results show that, following conversion to an integrated EHR, providing access to historical anesthesia records by maintaining the legacy AIMS is not an effective strategy to promote review of such records as part of the preoperative evaluation process. Because such records provide important information for many patients, providing linked access to such records within the EHR as part of the patient encounter may be a more effective approach.

Validation of a New Method to Automatically Select Cases With Intraoperative Red Blood Cell Transfusion for Audit.

BACKGROUND: Hospitals review allogeneic red blood cell (RBC) transfusions for appropriateness. Audit criteria have been published that apply to 5 common procedures. We expanded on this work to study the management decision of selecting which cases involving transfusion of at least 1 RBC unit to audit (review) among all surgical procedures, including those previously studied. METHODS: This retrospective, observational study included 400,000 cases among 1891 different procedures over an 11-year period. There were 12,616 cases with RBC transfusion. We studied the proportions of cases that would be audited based on criteria of nadir hemoglobin (Hb) greater than the hospital's selected transfusion threshold, or absent Hb or missing estimated blood loss (EBL) among procedures with median EBL <500 mL. This threshold EBL was selected because it is approximately the volume removed during the donation of a single unit of whole blood at a blood bank. Missing EBL is important to the audit decision for cases in which the procedures' median EBL is <500 mL because, without an indication of the extent of bleeding, there are insufficient data to assume that there was sufficient blood loss to justify the transfusion. RESULTS: Most cases (>50%) that would be audited and most cases (>50%) with transfusion were among procedures with median EBL <500 mL (P < .0001). Among cases with transfusion and nadir Hb >9 g/dL, the procedure's median EBL was <500 mL for 3.0 times more cases than for procedures having a median EBL ≥500 mL. A greater percentage of cases would be recommended for audit based on missing values for Hb and/or EBL than based on exceeding the Hb threshold among cases of procedures with median EBL ≥500 mL (P < .0001). There were 3.7 times as many cases with transfusion that had missing values for Hb and/or EBL than had a nadir Hb >9 g/dL and median EBL for the procedure ≥500 mL. CONCLUSIONS: An automated process to select cases for audit of intraoperative transfusion of RBC needs to consider the median EBL of the procedure, whether the nadir Hb is below the hospital's Hb transfusion threshold for surgical cases, and the absence of either a Hb or entry of the EBL for the case. This conclusion applies to all surgical cases and procedures.

Perioperative Temperature Measurement Considerations Relevant to Reporting Requirements for National Quality Programs Using Data From Anesthesia Information Management Systems.

BACKGROUND: Perioperative hypothermia may increase the incidences of wound infection, blood loss, transfusion, and cardiac morbidity. US national quality programs for perioperative normothermia specify the presence of at least 1 "body temperature" ≥35.5°C during the interval from 30 minutes before to 15 minutes after the anesthesia end time. Using data from 4 academic hospitals, we evaluated timing and measurement considerations relevant to the current requirements to guide hospitals wishing to report perioperative temperature measures using electronic data sources. METHODS: Anesthesia information management system databases from 4 hospitals were queried to obtain intraoperative temperatures and intervals to the anesthesia end time from discontinuation of temperature monitoring, end of surgery, and extubation. Inclusion criteria included age >16 years, use of a tracheal tube or supraglottic airway, and case duration ≥60 minutes. The end-of-case temperature was determined as the maximum intraoperative temperature recorded within 30 minutes before the anesthesia end time (ie, the temperature that would be used for reporting purposes). The fractions of cases with intervals >30 minutes between the last intraoperative temperature and the anesthesia end time were determined. RESULTS: Among the hospitals, averages (binned by quarters) of 34.5% to 59.5% of cases had intraoperative temperature monitoring discontinued >30 minutes before the anesthesia end time. Even if temperature measurement had been continued until extubation, averages of 5.9% to 20.8% of cases would have exceeded the allowed 30-minute window. Averages of 8.9% to 21.3% of cases had end-of-case intraoperative temperatures <35.5°C (ie, a quality measure failure). CONCLUSIONS: Because of timing considerations, a substantial fraction of cases would have been ineligible to use the end-of-case intraoperative temperature for national quality program reporting. Thus, retrieval of postanesthesia care unit temperatures would have been necessary. A substantive percentage of cases had end-of-case intraoperative temperatures below the 35.5°C threshold, also requiring postoperative measurement to determine whether the quality measure was satisfied. Institutions considering reporting national quality measures for perioperative normothermia should consider the technical and logistical issues identified to achieve a high level of compliance based on the specified regulatory language.