Use of herbal medication in the perioperative period: Potential adverse drug interactions.

Use of herbal medications and supplements has experienced immense growth over the last two decades, with retail sales in the USA exceeding $13 billion in 2021. Since the Dietary Supplement Health and Education Act (DSHEA) of 1994 reduced FDA oversight, these products have become less regulated. Data from 2012 shows 18% of U.S. adults used non-vitamin, non-mineral natural products. Prevalence varies regionally, with higher use in Western states. Among preoperative patients, the most commonly used herbal medications included garlic, ginseng, ginkgo, St. John's wort, and echinacea. However, 50-70% of surgical patients fail to disclose their use of herbal medications to their physicians, and most fail to discontinue them preoperatively. Since herbal medications can interact with anesthetic medications administered during surgery, the American Society of Anesthesiologists (ASA) and the American Association of Nurse Anesthetists (AANA) recommend stopping herbal medications 1-2 weeks before elective surgical procedures. Potential adverse drug effects related to preoperative use of herbal medications involve the coagulation system (e.g., increasing the risk of perioperative bleeding), the cardiovascular system (e.g., arrhythmias, hypotension, hypertension), the central nervous system (e.g., sedation, confusion, seizures), pulmonary (e.g., coughing, bronchospasm), renal (e.g., diuresis) and endocrine-metabolic (e.g., hepatic dysfunction, altered metabolism of anesthetic drugs). During the preoperative evaluation, anesthesiologists should inquire about the use of herbal medications to anticipate potential adverse drug interactions during the perioperative period.

Domains Influencing Faculty Decisions on the Level of Supervision Required for Anesthesiology EPAs with Analysis of Feedback Comments.

OBJECTIVE: The purpose of this qualitative study was to examine responses related to entrustment and feedback comments from an assessment tool. DESIGN: Qualitative analyses using semi-structured interviews and analysis of narrative comments. SETTING: Main hospital OR suite at a large academic medical center. PARTICIPANTS: faculty, and residents who work in the OR suite. RESULTS: Seven of the 14 theoretical domains from the Theoretical Domains Framework were identified as influencing faculty decision on entrustment: knowledge, skills, intention, memory/attention/decision processes, environmental context, and resources, beliefs of capabilities, and reinforcement. The majority (651/1116 (58.4%)) of faculty comments were critical/modest praise and relevant, consistent across all 6 EPAs. The written in feedback comments for all 1,116 Web App EPA assessments yielded a total of 1,599 sub-competency specific responses. These responses were mapped to core competencies, and at least once to 13 of the 23 ACGME subcompetencies. CONCLUSIONS: Domains identified as influencing faculty decision on entrustment were knowledge, skills, intention, memory/attention/decision processes, environmental context, and resources, beliefs of capabilities, and reinforcement. Most narrative feedback comments were critical/modest praise and relevant, consistent across each of the EPAs.

Postoperative electrocardiography changes: To worry or not to worry.

Abnormal postoperative electrocardiograms are not uncommon, oftentimes leading to further cardiac workup especially when the findings are new and not easily explainable. A forty-year-old woman, with a history of left breast cancer status post bilateral mastectomies and reconstructions, presented for robot-assisted low-anterior resection secondary to rectal cancer. Postoperative electrocardiogram showed poor R wave progression, biphasic T waves in V2-4, and possible anterior wall ischemia. Her electrocardiogram from 6 years ago was normal. No recent electrocardiogram was available for comparison. Initially, the abnormal postoperative electrocardiogram appeared worrisome. However, the patient was completely asymptomatic, and all vital signs were normal. Cardiac point-of-care ultrasound showed normal parasternal long and short axis views. The biphasic T waves in V2-4 were suggestive of Wellens syndrome, but the accompanying poor R wave progression was not consistent with the diagnostic criteria. The anesthesiologist then remembered the patient's history of the presence of a left breast implant and suspected it might have caused the changes on the electrocardiogram. A literature search did find one publication that shows approximately 45% of patients with breast implants present with electrocardiogram changes, including poor R wave progression and negative T waves. Therefore, no further cardiac workup was ordered for our patient. She was discharged home 3 days later. Breast implants and electrocardiogram changes are a lesser-known topic. Obtaining a pre-operative electrocardiogram should be considered in patients with previous breast implants, to serve as a baseline for comparison if the patient were to need another electrocardiogram in the future.

Electrographic lead I and V5 monitoring could have detected a missed left-side pneumothorax intraoperatively.

We present an EKG monitoring strategy to detect pneumothorax during high-risk surgery. In the literature, EKG changes and pneumothorax are well-described. However, anesthesiologists only monitor lead II on a three-lead EKG system in the operating room. In our case, there was only a subtle change in lead II for a left-sided pneumothorax, which could have been easily missed. On the contrary, there was a marked QRS amplitude reduction and T wave flattening/inversion in lead I and V5 . We recommend lead V5 be added to the continuous monitoring and lead I be periodically checked for surgeries known to potentially cause pneumothorax.

Experiences and Perspectives on Stressors and Organizational Strategies to Bolster Resiliency During the COVID-19 Pandemic: A Qualitative Study of Health Care Workers at a Tertiary Medical Center.

OBJECTIVE: This qualitative study included a sample of health care workers (HCWs) at a tertiary care center providing direct care to patients with COVID-19 to explore experiences and perceptions regarding care delivery during the COVID-19 pandemic as well as factors that helped HCWs cope with the challenges of the pandemic. Methods: Grounded theory methodology was used to conduct virtual focus groups with a semistructured interview guide May to June 2020. Results: We identified major themes related to (1) HCWs' emotions during the pandemic, (2) the perceived triggers of these feelings, (3) organizational factors that made HCWs feel more supported and appreciated, and (4) personal factors that helped HCWs cope with the pandemic. Conclusion: Results highlighted the stress and challenges associated with exposure to SARS-CoV-2. The findings can help inform interventions to support HCWs during pandemics and other crises.

Adverse Effects Associated with Patient-Controlled Analgesia with Ketamine Combined with Opioids and Ketamine Infusion with PCA Bolus in Postoperative Spine Patients: A Retrospective Review.

Objective: There has been increasing use of ketamine at subanesthetic doses as an adjunct to opioids in perioperative pain management. There are several known adverse drug effects (ADEs) associated with ketamine. However, the incidence of ADEs with ketamine infusions with patient-controlled analgesia (PCA) boluses compared with combined opioid and ketamine PCAs is not well described. The objectives of this study were to compare the incidence and type of ADEs in postoperative spine surgery patients on ketamine infusions with as-needed PCA boluses to patients on combined opioid and ketamine PCAs. Methods: The medical records of patients who underwent spine surgery between March 2016 and March 2020 who were postoperatively treated with a ketamine infusion and as-needed PCA boluses and parenteral opioids or treated with a combined opioid and ketamine PCA were reviewed. Perioperative information including patient characteristics and preoperative morphine equivalent daily dose (MEDD) were collected. Patient charts were reviewed for ADEs including psychological and neurological side effects, nausea, and new-onset tachycardia. Results: A total of 315 patients met the inclusion criteria and were included in the final analysis. Of these patients, 121 experienced at least one ADE (38%). Sixteen of the 68 ketamine infusion with PCA bolus patients (24%), 77 of the 203 hydromorphone and ketamine patients (38%), and 28 of the 44 morphine and ketamine patients (64%) experienced an ADE [p<0.01]. In patients with preoperative MEDD ≤ 90, nausea was the only ADE that differed significantly among the three groups. Conclusion: This retrospective analysis suggests that postoperative spine patients treated with a ketamine infusion with as-needed PCA boluses and parenteral opioids were associated with fewer ADEs when compared to an intravenous combined opioid and ketamine PCA. In patients with preoperative MEDD ≤ 90, nausea with and without emesis was the only ADE that showed statistically significant difference amongst the three groups.

Impact of chronic medications in the perioperative period -anesthetic implications (Part II).

Background: This review article discusses the pharmacodynamic effects of the most commonly used chronic medications by patients undergoing elective surgical procedures, namely cardiovascular drugs (e.g., beta blockers, alpha-2 agonist, calcium channel blockers, ACE inhibitors, diuretics, etc.), lipid-lowering drugs, gastrointestinal medications (H2-blockers, proton pump inhibitors), pulmonary medications (inhaled ß-agonists, anticholinergics,), antibiotics (tetracyclines, clindamycin and macrolide, linezolid.), opioids and non-opioids analgesics (NSAIDs, COX-2 inhibitors, acetaminophen), gabapentanoids, erectile dysfunction (ED) drugs, psychotropic drugs (tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAOI], selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], and cannabinol-containing drugs).  In addition, the potential adverse drug-interactions between these chronic medications and commonly used anesthetic drugs during the perioperative period will be reviewed. Finally, recommendations regarding the management of chronic medications during the preoperative period will be provided.Materials and Methods: An online search was conducted from January 2000 through February 2021 with the Medline database through PubMed and Google Scholar using the following search terms/keywords: "chronic medications in the perioperative period", and "chronic medications and anesthetic implications." In addition, we searched for anesthetic side effects associated with the major drug groups.Results and Conclusions: An understanding of the pharmacodynamic effects of most used chronic medications is important to avoid untoward outcomes in the perioperative period. These drug interactions may result in altered efficacy and toxicity of the anesthetic medications administered during surgery. These drug-drug interactions can also affect the morbidity, mortality, recovery time of surgical patients and acute relapse of chronic illnesses which could lead to last minute cancellation of surgical procedures. Part II of this two-part review article focuses on the reported interactions between most commonly taken chronic medications by surgical patients and anesthetic and analgesic drugs, as well as recommendations regarding the handling these chronic medications during the perioperative period.

Impact of chronic medications in the perioperative period: mechanisms of action and adverse drug effects (Part I).

Background: This review article discusses the pharmacology of the most commonly used chronic medications in patients undergoing elective surgical procedures. The mechanism of action and adverse side effects of cardiovascular medications (e.g., beta blockers, alpha-2 agonist, calcium channel blockers, ACE inhibitors, diuretics), lipid-lowering drugs, gastrointestinal medications (H2-blockers, proton pump inhibitors), pulmonary medications (inhaled ß-agonists, anticholinergics,), antibiotics (tetracyclines, clindamycin and macrolide, linezolid), opioids and non-opioids analgesics (NSAIDs, COX-2 inhibitors, acetaminophen), gabapentanoids, erectile dysfunction (ED) drugs, and psychotropic drugs (tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAOI], selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], and cannabinol-containing drugs) will be reviewed.Materials and Methods: An online search was conducted from January 2000 through February 2021 with the Medline database through PubMed and Google Scholar using the following search terms/keywords: "chronic medications in the perioperative period", and "chronic medications and anesthetic implications." In addition, we searched for anesthetic side effects associated with the major drug groups.Results and Conclusions: An understanding of the pharmacology and pharmacokinetics of most used chronic medications is important to avoid untoward outcomes in the perioperative period. These drug interactions may result in altered efficacy and toxicity of the anesthetic medications administered during surgery. These drug-drug interactions can also effect the morbidity, mortality, and recovery time of surgical patients. Part I of this two-part review article focuses on the mechanisms of action and adverse side effects of the chronic medications most commonly taken by surgical patients in the preoperative period.

Management strategies for the treatment and prevention of postoperative/postdischarge nausea and vomiting: an updated review.

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) remain common and distressing complications following surgery. The routine use of opioid analgesics for perioperative pain management is a major contributing factor to both PONV and PDNV after surgery. PONV and PDNV can delay discharge from the hospital or surgicenter, delay the return to normal activities of daily living after discharge home, and increase medical costs. The high incidence of PONV and PDNV has persisted despite the introduction of many new antiemetic drugs (and more aggressive use of antiemetic prophylaxis) over the last two decades as a result of growth in minimally invasive ambulatory surgery and the increased emphasis on earlier mobilization and discharge after both minor and major surgical procedures (e.g. enhanced recovery protocols). Pharmacologic management of PONV should be tailored to the patient's risk level using the validated PONV and PDNV risk-scoring systems to encourage cost-effective practices and minimize the potential for adverse side effects due to drug interactions in the perioperative period. A combination of prophylactic antiemetic drugs with different mechanisms of action should be administered to patients with moderate to high risk of developing PONV. In addition to utilizing prophylactic antiemetic drugs, the management of perioperative pain using opioid-sparing multimodal analgesic techniques is critically important for achieving an enhanced recovery after surgery. In conclusion, the utilization of strategies to reduce the baseline risk of PONV (e.g. adequate hydration and the use of nonpharmacologic antiemetic and opioid-sparing analgesic techniques) and implementing multimodal antiemetic and analgesic regimens will reduce the likelihood of patients developing PONV and PDNV after surgery.

Assessment Scores of a Mock Objective Structured Clinical Examination Administered to 99 Anesthesiology Residents at 8 Institutions.

BACKGROUND: Objective Structured Clinical Examinations (OSCEs) are used in a variety of high-stakes examinations. The primary goal of this study was to examine factors influencing the variability of assessment scores for mock OSCEs administered to senior anesthesiology residents. METHODS: Using the American Board of Anesthesiology (ABA) OSCE Content Outline as a blueprint, scenarios were developed for 4 of the ABA skill types: (1) informed consent, (2) treatment options, (3) interpretation of echocardiograms, and (4) application of ultrasonography. Eight residency programs administered these 4 OSCEs to CA3 residents during a 1-day formative session. A global score and checklist items were used for scoring by faculty raters. We used a statistical framework called generalizability theory, or G-theory, to estimate the sources of variation (or facets), and to estimate the reliability (ie, reproducibility) of the OSCE performance scores. Reliability provides a metric on the consistency or reproducibility of learner performance as measured through the assessment. RESULTS: Of the 115 total eligible senior residents, 99 participated in the OSCE because the other residents were unavailable. Overall, residents correctly performed 84% (standard deviation [SD] 16%, range 38%-100%) of the 36 total checklist items for the 4 OSCEs. On global scoring, the pass rate for the informed consent station was 71%, for treatment options was 97%, for interpretation of echocardiograms was 66%, and for application of ultrasound was 72%. The estimate of reliability expressing the reproducibility of examinee rankings equaled 0.56 (95% confidence interval [CI], 0.49-0.63), which is reasonable for normative assessments that aim to compare a resident's performance relative to other residents because over half of the observed variation in total scores is due to variation in examinee ability. Phi coefficient reliability of 0.42 (95% CI, 0.35-0.50) indicates that criterion-based judgments (eg, pass-fail status) cannot be made. Phi expresses the absolute consistency of a score and reflects how closely the assessment is likely to reproduce an examinee's final score. Overall, the greatest (14.6%) variance was due to the person by item by station interaction (3-way interaction) indicating that specific residents did well on some items but poorly on other items. The variance (11.2%) due to residency programs across case items was high suggesting moderate variability in performance from residents during the OSCEs among residency programs. CONCLUSIONS: Since many residency programs aim to develop their own mock OSCEs, this study provides evidence that it is possible for programs to create a meaningful mock OSCE experience that is statistically reliable for separating resident performance.

Intraoperative Pulmonary Embolism Diagnosed by Rescue Transesophageal Echocardiography in a Morbidly Obese Patient Undergoing Orthopedic Surgery following Motor Vehicle Crash.

A case of intraoperative pulmonary embolism diagnosed by rescue transesophageal echocardiography in a morbidly obese patient undergoing orthopedic surgery following motor vehicle crash, who developed acute and persistent tachycardia, hypotension, and reduction of end-tidal CO2 during general and regional anesthesia, is described.

Age exacerbates surgery-induced cognitive impairment and neuroinflammation in Sprague-Dawley rats: the role of IL-4.

Age is the most prominent risk factor for the development of postoperative cognitive dysfunction. This study investigated the potential role of anti-inflammatory interleukin (IL)-4 in age-related differences of surgery-induced cognitive deficits and neuroinflammatory responses. Both adult and aged Sprague-Dawley male rats were subjected to partial hepatectomy or partial hepatectomy with a cisterna magna infusion of IL-4. On postoperative days 1, 3, and 7, the rats were subjected to a reversed Morris water maze test. Hippocampal IL-1ß, IL-6, IL-4, and IL-4 receptor (IL-4R) were measured at each time point. Brain derived neurotrophic factor (BDNF), synaptophysin, Ionized calcium-binding adapter molecule 1 (Iba-1), microglial M2 phenotype marker Arg1, and CD200 were also examined in the hippocampus. Age induced an exacerbated cognitive impairment and an amplified neuroinflammatory response triggered by surgical stress on postoperative days 1 and 3. A corresponding decline in the anti-inflammatory cytokine IL-4 and BDNF were also found in the aged rats at the same time point. Treatment with IL-4 downregulated the expression of proinflammatory cytokines (e.g., IL-1ß and IL-6), increased the levels of BDNF and synaptophysin in the brain and improved the behavioral performance. An increased Arg1 expression and a high level of CD200 were also observed after a cisterna magna infusion of IL-4. An age-related decrease in IL-4 expression exacerbated surgery-induced cognitive deficits and exaggerated the neuroinflammatory responses. Treatment with IL-4 potentially attenuated these effects by enhancing BDNF and synaptophysin expression, inhibiting microglia activation and decreasing the associated production of proinflammatory cytokines.

Arterial CO2 as a Potent Coronary Vasodilator: A Preclinical PET/MR Validation Study with Implications for Cardiac Stress Testing.

Myocardial blood flow (MBF) is the critical determinant of cardiac function. However, its response to increases in partial pressure of arterial CO2 (PaCO2), particularly with respect to adenosine, is not well characterized because of challenges in blood gas control and limited availability of validated approaches to ascertain MBF in vivo. Methods: By prospectively and independently controlling PaCO2 and combining it with 13N-ammonia PET measurements, we investigated whether a physiologically tolerable hypercapnic stimulus (∼25 mm Hg increase in PaCO2) can increase MBF to that observed with adenosine in 3 groups of canines: without coronary stenosis, subjected to non-flow-limiting coronary stenosis, and after preadministration of caffeine. The extent of effect on MBF due to hypercapnia was compared with adenosine. Results: In the absence of stenosis, mean MBF under hypercapnia was 2.1 ± 0.9 mL/min/g and adenosine was 2.2 ± 1.1 mL/min/g; these were significantly higher than at rest (0.9 ± 0.5 mL/min/g, P < 0.05) and were not different from each other (P = 0.30). Under left-anterior descending coronary stenosis, MBF increased in response to hypercapnia and adenosine (P < 0.05, all territories), but the effect was significantly lower than in the left-anterior descending coronary territory (with hypercapnia and adenosine; both P < 0.05). Mean perfusion defect volumes measured with adenosine and hypercapnia were significantly correlated (R = 0.85) and were not different (P = 0.12). After preadministration of caffeine, a known inhibitor of adenosine, resting MBF decreased; and hypercapnia increased MBF but not adenosine (P < 0.05). Conclusion: Arterial blood CO2 tension when increased by 25 mm Hg can induce MBF to the same level as a standard dose of adenosine. Prospectively targeted arterial CO2 has the capability to evolve as an alternative to current pharmacologic vasodilators used for cardiac stress testing.

A novel visual facial anxiety scale for assessing preoperative anxiety.

BACKGROUND: There is currently no widely accepted instrument for measuring preoperative anxiety. The objective of this study was to develop a simple visual facial anxiety scale (VFAS) for assessing acute preoperative anxiety. METHODS: The initial VFAS was comprised of 11 similarly styled stick-figure reflecting different types of facial expressions (Fig 1). After obtaining IRB approval, a total of 265 participant-healthcare providers (e.g., anesthesiologists, anesthesiology residents, and perioperative nurses) were recruited to participate in this study. The participants were asked to: (1) rank the 11 faces from 0-10 (0 = no anxiety, while 10 = highest anxiety) and then to (2) match one of the 11 facial expression with a numeric verbal rating scale (NVRS) (0 = no anxiety and 10 = highest level of anxiety) and a specific categorical level of anxiety, namely no anxiety, mild, mild-moderate, moderate, moderate-high or highest anxiety. Based on these data, the Spearman correlation and frequencies of the 11 faces in relation to the 11-point numerical anxiety scale and 6 categorical anxiety levels were calculated. The highest frequency of a face assigned to a level of the numerical anxiety scale resulted in a finalized order of faces corresponding to the 11-point numeric rating scale. RESULTS: The highest frequency for each of the NVRS anxiety scores were as follow: A0, A1, A2, A3, A4, A5, A7, A6, A8, A9 and A10 (Fig 2). For the six categorical anxiety levels, a total of 260 (98.1%) participants chose the face A0 as representing 'no' anxiety, 250 (94.3%) participants chose the face A10 as representing 'highest' anxiety and 147 (55.5%) participants chose the face A8 as representing 'moderate-high' anxiety. Spearman analysis showed a significant correlation between the faces A3 and A5 assigned to the mild-moderate anxiety category (r = 0.58), but A5 was ultimately chosen due to its higher frequency compared to the frequency of A3 (30.6% vs 24.9%)(Fig 3). Similarly, the correlation of the faces A7 and A6 was significantly correlated with moderate anxiety (r = 0.87), but A7 remained because of its higher frequency (35.9% vs 22.6%). Using frequency and Spearman correlations, the final order of the faces assigned to the categories none, mild, mild-moderate, moderate, moderate-high and highest anxiety levels was A0, A1, A5, A7, A8 and A10, respectively (Fig 4). CONCLUSION: The proposed VFAS was a valid tool for assessing the severity of acute [state] anxiety, and could be easy to administer in routine clinical practice.

The Combination of IV and Perineural Dexamethasone Prolongs the Analgesic Duration of Intercostal Nerve Blocks Compared with IV Dexamethasone Alone.

Objective: The use of multiple-level, single-injection intercostal nerve blocks for pain control following video-assisted thorascopic surgery (VATS) is limited by the analgesic duration of local anesthetics. This study examines whether the combination of perineural and intravenous (IV) dexamethasone will prolong the duration of intraoperatively placed intercostal nerve blocks following VATS compared with IV dexamethasone and a perineural saline placebo. Design: Prospective, double-blind, randomized placebo-controlled trial. Setting: Single level-1 academic trauma center. Subjects: Forty patients undergoing a unilateral VATS under the care of a single surgeon. Methods: Patients were randomly assigned to two groups and received an intercostal nerve block containing 1) 0.5% bupivacaine with epinephrine and 1 ml of 0.9% saline or 2) 0.5% bupivacaine with epinephrine and 1 ml of a 4 mg/ml dexamethasone solution. All patients received 8 mg of IV dexamethasone. Results: Group 2 had lower NRS-11 scores at post-operative hours 8 (5.05, SD = 2.13 vs 3.50, SD = 2.50; p = 0.04), 20 (4.30, SD = 2.96 vs 2.26, SD = 2.31; p = 0.02), and 24 (4.53, SD = 1.95 vs 2.26, SD = 2.31; p = 0.02). Equianalgesic opioid requirement was decreased in group 2 at 32 hours (5.78 mg, SD = 5.77 vs 1.67 mg, SD = 3.49; p = 0.02). Group 2 also had greater FEV1 measured at 8, 12, 24, and 44 hours; greater FVC at 24 hours; greater PEF at 28 through 48 hours; and greater FEV1/FVC at 8 and 36 hours. Conclusions: The combination of IV and perineural dexamethasone prolonged the duration of a single-injection bupivacaine intercostal nerve block as measured by NRS-11 compared with IV dexamethasone alone at 24 hours. Reduced NRS-11 at other times, reduced opioid requirements, and increased PFTs were observed in group 2.

An update on pain management for elderly patients undergoing ambulatory surgery.

PURPOSE OF REVIEW: The aim of this review is to provide an overview of the drugs and techniques used for multimodal postoperative pain management in the older population undergoing surgery in the ambulatory setting. RECENT FINDINGS: Interest has grown in the possibility of adding adjuncts to a single shot nerve block in order to prolong the local anesthetic effect. The rapid and short-acting local anesthetics for spinal anesthesia are potentially beneficial for day-case surgery in the older population because of shorter duration of the motor block, faster recovery, and less transient neurologic symptoms. Another recent advance is the introduction of intravenous acetaminophen, which can rapidly achieve rapid peak plasma concentration (<15 min) following infusion and analgesic effect in ∼5 min with a duration of action up to 4 h. SUMMARY: The nonopioid analgesic therapies will likely assume an increasingly important role in facilitating the recovery process and improving the satisfaction for elderly ambulatory surgery patients. Strategies to avoid the use of opioids and minimize opioid-related side-effects is an important advance as we expand on the use of ambulatory surgery for the aging population.

Perioperative factors associated with Hospital Consumer Assessment of Healthcare Providers and Systems responses of total hip arthroplasty patients.

OBJECTIVE: To determine perioperative treatments and events associated with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) responses among patients who undergo total hip arthroplasties (THAs) and total knee arthroplasties (TKAs). DESIGN: Retrospective analysis. SETTING: Single tertiary care, academic, urban, level 1 trauma center. PARTICIPANTS: Final cohort represents 301 consecutive surgical inpatients meeting criteria for evaluation by HCAHPS survey. EXPOSURES: Responses to 4 HCAHPS questions were analyzed against perioperative treatments and events. MEASURES: Positive and negative responses to HCAHPS questions. RESULTS: THA patients responding affirmatively to both pain specific and general satisfaction were associated with preoperative use of chronic nonsteroidal anti-inflammatory drugs. In addition, THA patients responding affirmatively "how often was your pain well controlled" were also associated decreased postanesthesia care unit (PACU) opioid requirement. TKA patients responding affirmatively to "what number would you use to rate this hospital" were associated with shorter PACU stays and lower final pain scores. TKA patients responding affirmatively to "would you recommend this hospital to your family" were associated with shorter lengths of stay in the hospital and in the PACU. TKA patients responding affirmatively to "How often did the hospital staff do everything to help with your pain" were not associated with any measured perioperative event. TKA patients responding affirmatively to "how often was your pain well controlled" were associated with older age, decreased use of preoperative chronic benzodiazepines, and increased use of preoperative midazolam. CONCLUSIONS: These data suggest that chronic use of nonsteroidal anti-inflammatory drugs is associated with improved overall satisfaction and satisfaction with pain in THA patients. Furthermore, increased PACU opioid use was negatively associated satisfaction with pain management. Age, lengths of stay preadmission medications, anxiolytic medications, and PACU pain scores are associated with patient satisfaction with regards to both pain management and overall satisfaction in TKA patients.

Propofol versus midazolam for premedication: a placebo­controlled, randomized double­blinded study.

BACKGROUND: It has been previously reported that subhypnotic doses of propofol could offer an advantage over midazolam for premedication. This study was designed to test the hypothesis that a 20 mg IV dose of propofol would be more effective than a standard 2 mg IV dose of midazolam for reducing acute anxiety prior to induction of anesthesia. METHODS: One hundred twenty outpatients scheduled to undergo orthopedic surgery were randomly assigned to one of three study groups: control (saline); propofol (20 mg); or midazolam (2 mg). Immediately before administering the study medication, each patient evaluated their level of acute anxiety and sedation on 11­point verbal rating scales (VRSs) 0=none- 10=highest, and they were also shown a picture. Upon arrival in the OR ~5 min after administering the study medication, anxiety and sedation levels were reassessed and a second picture was shown. At discharge from the recovery area, anxiety and sedation levels and their ability to recall the two pictures were reassessed. RESULTS: Compared to the saline group, both propofol and midazolam produced significant increases in the patient's level of sedation upon entering the OR (+2.5±2.4 vs. +4.6±2.5 and +5.2±2.3, respectively [p<0.001]). Propofol was effective as midazolam compared to saline in reducing the patient's level of preinduction anxiety (from 3.2±2.2 to1.8±1.8 vs. 3.1±2.2 to 2.3±2.1 and 2.7±1.8 to 2.8±2.1, respectively). Propofol produced more pain on injection and midazolam significantly reduced recall of the second picture. CONCLUSIONS: When administered ~5 min prior to entering the OR, propofol, 20mg IV, was as effective as midazolam 2mg IV in reducing anxiety.

Comparison of the C-MAC video laryngoscope to a flexible fiberoptic scope for intubation with cervical spine immobilization.

STUDY OBJECTIVE: To compare the C-MAC video laryngoscope to the standard flexible fiberoptic scope (FFS) with an eye piece (but without a camera or a video screen) for intubation of patients undergoing cervical spine surgery with manual inline stabilization. The primary end point was the time to achieve successful tracheal intubation. Secondary end points included glottic view at intubation and number of intubation attempts. DESIGN: Prospective, randomized, single-blinded study. SETTING: Cedars Sinai Medical Center in Los Angeles, CA. PATIENTS: One hundred forty patients (American Society of Anaesthesiologists physical status I-III), aged 18 to 80years undergoing elective cervical spine surgery. INTERVENTION: Patients were prospectively randomized to undergo tracheal intubation using either an FFS (n=70) or the C-MAC video laryngoscope (n=70). MEASUREMENTS: After performing a preoperative airway evaluation, patients underwent a standardized induction sequence. The glottic view was assessed at the time of tracheal tube placement using the Cormack-Lehane and percentage of glottic opening scoring systems. In addition, the time required for successful insertion of the tracheal tube, number of intubation attempts to secure the airway, the need for adjuvant airway devices, hemodynamic changes, adverse events, and any airway-related trauma were recorded. MAIN RESULTS: The glottic view at the time of intubation did not differ significantly with the 2 devices; however, the C-MAC facilitated more rapid tracheal intubation compared with the FFS (P=.001). The peak heart rate response following insertion of the tracheal tube was also reduced (P=.004) in the C-MAC (vs FFS) group. CONCLUSION: The C-MAC may offer an advantage over the FFS with respect to the time required to obtain glottic view and successful placement of the tracheal tube in patients requiring cervical spine immobilization.