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.).

Pro and Con: How Important Is the Exact Location of Adductor Canal and Femoral Triangle Blocks?

In this Pro-Con commentary article, we debate the importance of anterior thigh block locations for analgesia following total knee arthroplasty. The debate is based on the current literature, our understanding of the relevant anatomy, and a clinical perspective. We review the anatomy of the different fascial compartments, the course of different nerves with respect to the fascia, and the anatomy of the nerve supply to the knee joint. The Pro side of the debate supports the view that more distal block locations in the anterior thigh increase the risk of excluding the medial and intermediate cutaneous nerves of the thigh and the nerve to the vastus medialis, while increasing the risk of spread to the popliteal fossa, making distal femoral triangle block the preferred location. The Con side of the debate adopts the view that while the exact location of local anesthetic injection appears anatomically important, it has not been proven to be clinically relevant.

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.

Etiology, management, and sequela of postdural puncture headache.

PURPOSE: The purpose of this article is to provide readers with a concise overview of the cause, incidence, treatment of, and sequalae of postdural puncture headaches (PDPH). Over the past 2 years, much data has been published on modifiable risk factors for PDPH, treatments for PDPH, and sequalae of PDPH particularly long-term. RECENT FINDINGS: There is emerging data about how modifiable risk factors for PDPH are not as absolute as once believed. There have been several new meta-analysis and clinical trials published, providing more data about effective therapies for PDPH. Significantly, much recent data has come out about the sequalae, particularly long-term of dural puncture. SUMMARY: Emerging evidence demonstrates that in patients who are at low risk of PDPH, needle type and gauge may be of no consequence in a patient developing a PDPH. Although epidural blood patch (EBP) remains the gold-standard of therapy, several other interventions, both medical and procedural, show promise and may obviate the need for EBP in patients with mild-moderate PDPH. Patients who endure dural puncture, especially accidental dural puncture (ADP) are at low but significant risk of developing short term issues as well as chronic pain symptoms.

Patient Involvement in Anesthesia Decision-making: A Qualitative Study of Knee Arthroplasty.

BACKGROUND: Calls to better involve patients in decisions about anesthesia-e.g., through shared decision-making-are intensifying. However, several features of anesthesia consultation make it unclear how patients should participate in decisions. Evaluating the feasibility and desirability of carrying out shared decision-making in anesthesia requires better understanding of preoperative conversations. The objective of this qualitative study was to characterize how preoperative consultations for primary knee arthroplasty arrived at decisions about primary anesthesia. METHODS: This focused ethnography was performed at a U.S. academic medical center. The authors audio-recorded consultations of 36 primary knee arthroplasty patients with eight anesthesiologists. Patients and anesthesiologists also participated in semi-structured interviews. Consultation and interview transcripts were coded in an iterative process to develop an explanation of how anesthesiologists and patients made decisions about primary anesthesia. RESULTS: The authors found variation across accounts of anesthesiologists and patients as to whether the consultation was a collaborative decision-making scenario or simply meant to inform patients. Consultations displayed a number of decision-making patterns, from the anesthesiologist not disclosing options to the anesthesiologist strictly adhering to a position of equipoise; however, most consultations fell between these poles, with the anesthesiologist presenting options, recommending one, and persuading hesitant patients to accept it. Anesthesiologists made patients feel more comfortable with their proposed approach through extensive comparisons to more familiar experiences. CONCLUSIONS: Anesthesia consultations are multifaceted encounters that serve several functions. In some cases, the involvement of patients in determining the anesthetic approach might not be the most important of these functions. Broad consideration should be given to both the applicability and feasibility of shared decision-making in anesthesia consultation. The potential benefits of interventions designed to enhance patient involvement in decision-making should be weighed against their potential to pull anesthesiologists' attention away from important humanistic aspects of communication such as decreasing patients' anxiety.

Opioid Stewardship Program and Postoperative Adverse Events: A Difference-in-differences Cohort Study.

BACKGROUND: A 6-month opioid use educational program consisting of webinars on pain assessment, postoperative and multimodal pain opioid management, safer opioid use, and preventing addiction coupled with on-site coaching and monthly assessments reports was implemented in 31 hospitals. The authors hypothesized the intervention would measurably reduce and/or prevent opioid-related harm among adult hospitalized patients compared to 33 nonintervention hospitals. METHODS: Outcomes were extracted from medical records for 12 months before and after the intervention start date. Opioid adverse events, evaluated by opioid overdose, wrong substance given or taken in error, naloxone administration, and acute postoperative respiratory failure causing prolonged ventilation were the primary outcomes. Opioid use in adult patients undergoing elective hip or knee arthroplasty or colorectal procedures was also assessed. Differences-in-differences were compared between intervention and nonintervention hospitals. RESULTS: Before the intervention, the incidence ± SD of opioid overdose, wrong substance given, or substance taken in error was 1 ± 0.5 per 10,000 discharges, and naloxone use was 117 ± 13 per 10,000 patients receiving opioids. The incidence of respiratory failure was 42 ± 10 per 10,000 surgical discharges. A difference-in-differences of -0.2 (99% CI, -1.1 to 0.6, P = 0.499) per 10,000 in opioid overdose, wrong substance given, or substance taken in error and -13.6 (99% CI, -29.0 to 0.0, P = 0.028) per 10,000 in respiratory failure was observed postintervention in the intervention hospitals; however, naloxone administration increased by 15.2 (99% CI, 3.8 to 30.0, P = 0.011) per 10,000. Average total daily opioid use, as well as the fraction of patients receiving daily opioid greater than 90 mg morphine equivalents was not different between the intervention and nonintervention hospitals. CONCLUSIONS: A 6-month opioid educational intervention did not reduce opioid adverse events or alter opioid use in hospitalized patients. The authors' findings suggest that despite opioid and multimodal analgesia awareness, limited-duration educational interventions do not substantially change the hospital use of opioid analgesics.

Risk factors for reintubation after anterior cervical discectomy and fusion surgery: evaluation of three observational data sets.

PURPOSE: Postoperative loss of airway requiring reintubation is a rare but potentially catastrophic complication following anterior cervical discectomy and fusion (ACDF). We sought to identify risk factors asscociated with reintubation within one day following ACDF. Attention was focused on patient demographics, comorbidities, and factors potentially linked to soft tissue swelling and hematoma formation that could compromise the upper airway. METHODS: We performed a retrospective cohort study of patients who underwent ACDF procedures at a high-volume institution from 2005 to 2014 (n = 3,041), participating hospitals in the National Surgical Quality Improvement Program (NSQIP) (n = 47,425), and Premier Healthcare (n = 233,633) databases from 2006 to 2016. Separate multivariable logistic regression models using the NSQIP and Premier samples were used to identify risk factors for reintubation within one day of ACDF. Odds ratios (OR) and 95% confidence intervals (CI) are reported. RESULTS: Incidence of reintubation within one day of ACDF was 0.19% in the institutional database and 0.21% in NSQIP and Premier databases. Risk factors for reintubation included older age, male sex, high comorbidity burden, procedures performed at large hospitals, non-elective procedures, Medicaid insurance, and use of heparin or more than one anticoagulant. Intravenous or oral steroid use (OR, 0.45; 95% CI, 0.36 to 0.56; P < 0.001) and delayed extubation (OR, 0.28 95% CI, 0.16 to 0.49; P < 0.001) were found to decrease risk of reintubation. CONCLUSIONS: Across three complementary data sets, incidence of reintubation within one day of ACDF was approximately 0.20%. Increased risk of reintubation associated with anticoagulant administration suggests upper airway hematoma as an underlying etiology. Steroid administration and delayed extubation may be useful in patients considered to be at higher risk for reintubation.

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.

Improved Quality of Recovery from Ambulatory Shoulder Surgery After Implementation of a Multimodal Perioperative Pain Management Protocol.

OBJECTIVES: Pain control after shoulder arthroscopy can be challenging, often relying on opioids. The study aims to measure the quality of recovery (QoR) before and after implementation of a "Multimodal Perioperative Pain Protocol" (MP3) in patients undergoing ambulatory shoulder arthroscopy. DESIGN: Prospective cohort study. SETTING: Free-standing ambulatory surgery facility of a tertiary care academic center. SUBJECTS: Patients undergoing ambulatory shoulder arthroscopy. METHODS: The primary end point of the study was the QoR-9 score at 24 hours, 48 hours, and one week after surgery. Secondary end points included 1) measuring the quality of pain management using the Revised American Pain Society Patient Oriented Questionnaire (APS-POQ-R) and 2) postoperative opioid requirements. RESULTS: Data from132 patients in the control group (pre-intervention) and 120 patients in the MP3 group were analyzed. The QoR-9 scores were significantly higher for the MP3 group at all time points, but only met the minimal clinical important difference threshold at 24 hours (13.4 vs 14.9, P < 0.05) and 48 hours (14.0 vs 15.0, P < 0.05) postoperatively. Patients reported better quality of pain management after implementation of the MP3 in the domains of pain intensity, pain interference with activity, and sleep, and they reported the presence of negative emotions up to two days after ambulatory shoulder surgery. In addition, this protocol significantly reduced opioid consumption up to three days after surgery. CONCLUSIONS: Implementation of the MP3 improved the overall QoR and many aspects of postoperative pain relief while reducing total opioid consumption in patients undergoing ambulatory shoulder surgery.

Risk Factors for Cerebral Desaturation Events During Shoulder Surgery in the Beach Chair Position.

PURPOSE: The goals of this study were 2-fold: (1) to determine the risk factors for cerebral desaturation events (CDEs) after implementation of a comprehensive surgical and anesthetic protocol consisting of patient risk stratification, maintenance of normotensive anesthesia, and patient positioning in a staged fashion, and (2) to assess for subclinical neurologic decline associated with intraoperative ischemic events through cognitive testing. METHODS: One hundred patients undergoing shoulder surgery in the beach chair position were stratified for risk of CDE based on Framingham stroke criteria, body mass index (BMI), and history of cerebrovascular accidents. Cerebral oxygen saturation was monitored with near-infrared spectroscopy. As per a standardized protocol, mean arterial pressure was maintained between 70 and 90 mm Hg. The head was raised in 2 stages separated by 3 minutes. CDE were defined as >20% drop from baseline or <55% O2 absolute threshold. Patients completed a Mini-Mental State Examination during preoperative examination and at the first postoperative visit. RESULTS: The CDE rate was 4% overall and 4.3% in patients undergoing general anesthesia. Forty-five patients were in the higher risk category, and all CDEs occurred in that group. Patients with a Framingham score ≥ 10 or BMI ≥ 35 who underwent general anesthesia had an increased risk of CDE (P = .04). No significant change was noted in Mini-Mental State Examination scores between pre- and postoperative visits. No correlation was shown between CDE and history of diabetes, smoking, cardiovascular disease, or left ventricular hypertrophy. CONCLUSIONS: Our observed CDE rate was lower than previously reported rates, likely because of risk stratification, staged positioning, and normotensive anesthesia. Framingham score ≥ 10 and BMI ≥ 35 are risk factors for CDE in the beach chair position. LEVEL OF EVIDENCE: Level II, prospective observational study with >80% follow-up.

Preoperative Risk Factor Score Predicts Malnutrition in Total Joint Arthroplasty Patients.

Malnutrition is a modifiable risk factor for poor outcomes in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). The purpose of this study is to highlight risk factors for hypoalbuminemia and develop a predictive model that identifies patients at risk for this condition before THA or TKA. The study retrospectively reviewed the National Surgical Quality Improvement Program database to analyze preoperative independent risk factors for a diagnosis of hypoalbuminemia in adult patients who underwent THA or TKA. These factors were used to create a preoperative risk model to predict hypoalbuminemia. Individuals with three or more risk factors in the seven-point model are predicted to have hypoalbuminemia in 20.4% of THA or 10.5% of TKA cases. Accurate identification of hypoalbuminemic patients may allow preoperative nutrition interventions to improve postoperative outcomes. (Journal of Surgical Orthopaedic Advances 28(2):97-103, 2019).

Regional anesthesia for vascular surgery: does the anesthetic choice influence outcome?

PURPOSE OF REVIEW: Outcomes following surgery are of major importance to clinicians, institutions and most importantly patients. This review examines whether regional anesthesia and analgesia influence outcome after vascular surgery. RECENT FINDINGS: Large database analyses of contemporary practice suggest that utilizing regional anesthesia for both open and endovascular aortic aneurysm repair, lower limb revascularization and carotid endarterectomy reduces morbidity, length of stay and possibly even mortality. Results from such analyses are limited by an inherent risk of bias but are nevertheless important given the number of patients required in randomized trials to detect differences in rare outcomes. There is minimal evidence that regional anesthesia influences longer term outcomes except for arteriovenous fistula surgery where brachial plexus blocks appear to improve 3-month fistula patency. SUMMARY: Patients undergoing vascular surgery often have multiple comorbidities and it is important to be able to outline both benefits and risks of regional anesthesia techniques. Regional anesthesia in vascular surgery allows avoidance of general anesthesia and does provide short-term benefits beyond superior analgesia. Evidence of long-term benefits is lacking in most procedures. Further work is required on newer patient centered outcomes.

Hospital-Based Acute Care Within 7 Days of Discharge After Outpatient Arthroscopic Shoulder Surgery.

BACKGROUND: The rate of hospital-based acute care (defined as hospital transfer at discharge, emergency department [ED] visit, or subsequent inpatient hospital [IP] admission) after outpatient procedure is gaining momentum as a quality metric for ambulatory surgery. However, the incidence and reasons for hospital-based acute care after arthroscopic shoulder surgery are poorly understood. METHODS: We studied adult patients who underwent outpatient arthroscopic shoulder procedures in New York State between 2011 and 2013 using the Healthcare Cost and Utilization Project database. ER visits and IP admissions within 7 days of surgery were identified by cross-matching 2 independent Healthcare Cost and Utilization Project databases. RESULTS: The final cohort included 103,476 subjects. We identified 1867 (1.80%, 95% confidence interval [CI], 1.72%-1.89%) events, and the majority of these encounters were ER visits (1643, or 1.59%, 95% CI, 1.51%-1.66%). Direct IP admission after discharged was uncommon (224, or 0.22%, 95% CI, 0.19%-0.24%). The most common reasons for seeking acute care were musculoskeletal pain (23.78% of all events). Nearly half of all events (43.49%) occurred on the day of surgery or on postoperative day 1. Operative time exceeding 2 hours was associated with higher odds of requiring acute care (odds ratio [OR], 1.28; 99% CI, 1.08-1.51). High-volume surgical centers (OR, 0.67; 99% CI, 0.58-0.78) and regional anesthesia (OR, 0.72; 99% CI, 0.56-0.92) were associated with lower odds of requiring acute care. CONCLUSIONS: The rate of hospital-based acute care after outpatient shoulder arthroscopy was low (1.80%). Complications driving acute care visits often occurred within 1 day of surgery. Many of the events were likely related to surgery and anesthesia (eg, inadequate analgesia), suggesting that anesthesiologists may play a central role in preventing acute care visits after surgery.

Safety in Acute Pain Medicine-Pharmacologic Considerations and the Impact of Systems-Based Gaps.

Objective: In the setting of an expanding prevalence of acute pain medicine services and the aggressive use of multimodal analgesia, an overview of systems-based safety gaps and safety concerns in the setting of aggressive multimodal analgesia is provided below. Setting: Expert commentary. Methods: Recent evidence focused on systems-based gaps in acute pain medicine is discussed. A focused literature review was conducted to assess safety concerns related to commonly used multimodal pharmacologic agents (opioids, nonsteroidal anti-inflammatory drugs, gabapentanoids, ketamine, acetaminophen) in the setting of inpatient acute pain management. Conclusions: Optimization of systems-based gaps will increase the probability of accurate pain assessment, improve the application of uniform evidence-based multimodal analgesia, and ensure a continuum of pain care. While acute pain medicine strategies should be aggressively applied, multimodal regimens must be strategically utilized to minimize risk to patients and in a comorbidity-specific fashion.

Effect of Local Anesthetic Concentration (0.2% vs 0.1% Ropivacaine) on Pulmonary Function, and Analgesia After Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Study.

OBJECTIVE: This study aims to assess diaphragmatic excursion and measure pulmonary functions as measures of the degree to which the phrenic nerve is blocked after ISB with two different concentrations of ropivacaine: 0.2% and 0.1%. DESIGN: Randomized, double-blinded study. SETTING AND PATIENTS: Ambulatory surgical facility. SUBJECTS: Fifty patients undergoing shoulder arthroscopy for rotator cuff repair. METHODS: Patients were randomized to receive ultrasound-guided ISB with 20 mL of either 0.2% or 0.1% ropivacaine. Diaphragmatic excursion was measured using M-mode ultrasound. Pulmonary functions were assessed by portable spirometer. Additional outcome data included oxygen saturation in post-anesthesia care unit (PACU), pain scores, quality of recovery scores (QOR), and opioid consumption over 72 hour period after surgery. RESULTS: Forced vital capacity (FVC) was significantly reduced 30 minutes after block placement and in PACU in the 0.2% group when compared with the 0.1% group (P = 0.04, P = 0.03, respectively). Forced expiratory volume (FEV1) was also significantly decreased in the 0.2% group in PACU when compared with the 0.1% group (P = 0.04). There were no significant differences in pain scores, length of stay, and total opioid consumption in PACU. Patients who received 0.2% ropivacaine had a longer block duration (18 vs 11.9 hours, P = 0.04) and used less opioid in the 72 hours after surgery (55 mg vs 102 mg codeine equivalents, P = 0.02), when they were compared to their counterparts who received 0.1% for their block. CONCLUSION: 0.1% ropivacaine may impair pulmonary function less than 0.2% ropivacaine. The clinical significance of these differences needs to be further studied.

The Risk of Falls After Total Knee Arthroplasty with the Use of a Femoral Nerve Block Versus an Adductor Canal Block: A Double-Blinded Randomized Controlled Study.

BACKGROUND: Adductor canal block (ACB) has emerged as an appealing alternative to femoral nerve block (FNB) that produces a predominantly sensory nerve block by anesthetizing the saphenous nerve. Studies have shown greater quadriceps strength preservation with ACB compared with FNB, but no advantage has yet been shown in terms of fall risk. The Tinetti scale is used by physical therapists to assess gait and balance, and total score can estimate a patient's fall risk. We designed this study to test the primary hypothesis that FNB results in a greater proportion of "high fall risk" patients postoperatively using the Tinetti score compared with ACB. METHODS: After institutional review board approval, informed written consent to participate in the study was obtained. Patients undergoing primary unilateral total knee arthroplasty were eligible for enrollment in this double-blind, randomized trial. Patients received either an ACB or FNB (20 mL of 0.5% ropivacaine) with catheter placement (8 mL/h of 0.2% ropivacaine) in the setting of multimodal analgesia. Continuous infusion was stopped in the morning of postoperative day (POD)1 before starting physical therapy (PT). On POD1, PT assessed the primary outcome using the Tinetti score for gait and balance. Patients were considered to be at high risk of falling if they scored <19. Secondary outcomes included manual muscle testing of the quadriceps muscle strength, Timed Up and Go (TUG) test, and ambulation distance on POD1 and POD2. The quality of postoperative analgesia and the quality of recovery were assessed with American Pain Society Patient Outcome Questionnaire Revised and Quality of Recovery-9 questionnaire, respectively. RESULTS: Sixty-two patients were enrolled in the study (31 ACB and 31 FNB). No difference was found in the proportion of "high fall risk" patients on POD1 (21/31 in the ACB group versus 24/31 in the FNB group [P = 0.7]; relative risk, 1.14 [95% confidence interval, 0.84-1.56]) or POD2 (7/31 in the ACB versus 14/31 in the FNB group [P = 0.06]; relative risk, 2.0 [95% confidence interval, 0.94-4.27]). The average distance of ambulation during PT and time to up and go were similar on POD1 and POD2. Manual muscle testing grades were significantly higher on POD1 in the ACB group when compared with that in the FNB (P = 0.001) (Wilcoxon-Mann-Whitney odds, 2.25 [95% confidence interval, 1.35-4.26]). There were no other differences in postoperative outcomes. CONCLUSIONS: ACB results in greater preservation of quadriceps muscle strength. Although we did not detect a significant reduction in fall risk when compared with FNB, based on the upper limit of the relative risk, it may very well be present. Further study is needed with a larger sample size.

Provocation of atrial fibrillation triggers during ablation: does the use of general anesthesia affect inducibility?

INTRODUCTION: The autonomic nervous system exerts important effects upon atrial fibrillation (AF) initiation. The strategy of anesthesia used during AF ablation may impact the provocation of AF triggers. We hypothesized that the use of general anesthesia (GA) would reduce the incidence of provokable AF triggers in patients undergoing AF ablation compared to patients studied while receiving only conscious sedation (CS). METHODS AND RESULTS: We performed a prospective, case control study comparing the incidence of provokable AF triggers in a consecutive series of patients undergoing AF ablation under GA using a standard trigger induction protocol. We compared the frequency and distribution of AF triggers to a second cohort of historical controls (matched for age, gender, left atrial dimension, and AF phenotype) who underwent ablation while receiving CS. We calculated that 44 total subjects (22 patients in each group) were required to detect a 50% reduction in the incidence of AF triggers in the GA cohort. There was no difference between the 2 groups in the rate of AF trigger inducibility (77% vs. 68%, P = 0.26) or the number of triggers provoked per patient (1.2 ± 0.8 vs. 1.3 ± 0.8, P = 0.38). Patients ablated under GA required higher doses of phenylephrine during the trigger induction protocol (408.3 mg [52-600] vs. 158.3 mg [0-75]; P = 0.003), and tended to require higher doses of isoproterenol to initiate triggers (92.8 mg [20-111] vs. 63.6 mg [6-103]; P = 0.25). CONCLUSION: AF trigger induction during GA is both safe and efficacious.

Low Albumin Levels, More Than Morbid Obesity, Are Associated With Complications After TKA.

BACKGROUND: Morbid obesity and malnutrition are thought to be associated with more frequent perioperative complications after TKA. However, morbid obesity and malnutrition often are co-occurring conditions. Therefore it is important to understand whether morbid obesity, malnutrition, or both are independently associated with more frequent perioperative complications. In addition, assessing the magnitude of an increase in complications and whether these complications are major or minor is important for both conditions. QUESTIONS/PURPOSES: We asked: (1) Is morbid obesity independently associated with more frequent major perioperative complications after TKA? (2) Are major perioperative complications after TKA more prevalent among patients with a low serum albumin? METHODS: The National Surgical Quality Improvement Program (NSQIP) database was analyzed from 2006 to 2013. Patients were grouped as morbidly obese (BMI ≥ 40 kg/m(2)) or nonmorbidly obese (BMI ≥ 18.5 kg/m(2) to < 40 kg/m(2)), or by low serum albumin (serum albumin level < 3.5 mg/dL) or normal serum albumin (serum albumin level ≥ 3.5 mg/dL). The study cohort included 77,785 patients, including 35,573 patients with a serum albumin level of 3.5 g/dL or greater and 1570 patients with a serum albumin level less than 3.5 g/dL. Therefore, serum albumin levels were available for only 37,173 of the 77,785 of the patients (48%). There were 66,382 patients with a BMI between 18.5 kg/m(2) and 40 kg/m(2) and 11,403 patients with a BMI greater than 40 kg/m(2). Data were recorded on patient mortality along with 21 complications reported in the NSQIP. We also developed three composite complication variables to represent risk of any infections, cardiac or pulmonary complications, and any major complications. For each complication, multivariate logistic regression analysis was performed. Independent variables included patient age, sex, race, BMI, American Society of Anesthesiologists classification, year of surgery, and Charlson comorbidity index score. RESULTS: Mortality was not increased in the morbidly obese group (0.14% vs 0.14%; p = 0.942). Patients who were morbidly obese were more likely to have progressive renal insufficiency (0.30% vs 0.10%; odds ratio [OR], 2.47; 95% CI, 1.27-4.29; p < 0.001), superficial infection (1.07% vs 0.55%; OR, 1.87; 95% CI, 1.39-2.51; p < 0.001), and sepsis (0.36% vs 0.23%; OR, 1.70; 95% CI, 1.04-2.53; p = 0.034) compared with patients who were not morbidly obese. Patients who were morbidly obese were less likely to require blood transfusion (8.68% vs 12.06%; OR, 0.70; 95% CI, 0.63-0.77; p < 0.001) compared with patients who were not morbidly obese. Morbid obesity was not associated with any of the other 21 perioperative complications recorded in the NSQIP database. With respect to the composite complication variables, patients who were morbidly obese had an increased risk of any infection (3.31% vs 2.41%; OR, 1.38; 95% CI, 1.16-1.64; p < 0.001) but not for cardiopulmonary or any major complication. The group with low serum albumin had higher mortality than the group with normal serum albumin (0.64% vs 0.15%; OR, 3.17; 95% CI, 1.58-6.35; p = 0.001). Patients in the low serum albumin group were more likely to have a superficial surgical site infection (1.27% vs 0.64%; OR, 1.27; 95% CI, 1.09-2.75; p = 0.020); deep surgical site infection (0.38% vs 0.12%; OR, 3.64; 95% CI, 1.54-8.63; p = 0.003); organ space surgical site infection (0.45% vs 0.15%; OR, 2.71; 95% CI, 1.23-5.97; p = 0.013); pneumonia (1.21 vs 0.29%; OR, 3.55; 95% CI, 2.14-5.89; p < 0.001); require unplanned intubation (0.51% vs 0.17%, OR, 2.24; 95% CI, 1.07-4.69; p = 0.033); and remain on a ventilator more than 48 hours (0.38% vs 0.07%; OR, 4.03; 95% CI, 1.64-9.90; p = 0.002). They are more likely to have progressive renal insufficiency (0.45 % vs 0.12%; OR, 2.71; 95% CI, 1.21-6.07; p = 0.015); acute renal failure (0.32% vs 0.06%; OR, 5.19; 95% CI, 1.96-13.73; p = 0.001); cardiac arrest requiring cardiopulmonary resuscitation (0.19 % vs 0.12%; OR, 3.74; 95% CI, 1.50-9.28; p = 0.005); and septic shock (0.38% vs 0.08%; OR, 4.4; 95% CI, 1.74-11.09; p = 0.002). Patients in the low serum albumin group also were more likely to require blood transfusion (17.8% vs 12.4%; OR, 1.56; 95% CI, 1.35-1.81; p < 0.001). In addition, among the three composite complication variables, any infection (5.0% vs 2.4%; OR, 2.0; 95% CI, 1.53-2.61; p < 0.001) and any major complication (2.4% vs 1.3%; OR, 1.41; 95% CI, 1.00-1.97; p = 0.050) were more prevalent among the patients with low serum albumin. There was no difference for cardiopulmonary complications. CONCLUSIONS: Morbid obesity is not independently associated with the majority of perioperative complications measured by the NSQIP and was associated only with increases in progressive renal insufficiency, superficial surgical site infection, and sepsis among the 21 perioperative variables measured. However, low serum albumin was associated with increased mortality and multiple additional major perioperative complications after TKA. Low serum albumin, more so than morbid obesity, is associated with major perioperative complications. This is an important finding, as low serum albumin may be more modifiable than morbid obesity in patients who are immobile or have advanced knee osteoarthritis. LEVEL OF EVIDENCE: Level III, prognostic study.